
Class 7\G 4=£_ 
Gojpgk^°____ 



COPYRIGHT DEPOSE 



A MANUAL 



PRACTICE OF MEDICINE, 



PREPARED 



ESPECIALLY FOR STUDENTS. 




BY 

A. A. STEVENS, A.M., M.D., 

INSTRUCTOR OF PHYSICAL DIAGNOSIS IN THE UNIVERSITY OF PENNSYLVANIA, 

AND DEMONSTRATOR OF PATHOLOGY IN THE WOMAN'S 

MEDICAL COLLEGE, PHILADELPHIA. 



" is an arch where through 

(jleams that untravelled world, whose margin fades 
Forever and forever as we move." 



1 LLUSTRATED. 


/ 




^/ 2-4 2- A 






^\ 






1892 J 




PHILADELPHIA 




B. 


SAUNDERS, 


918 


Walnut Street. 
1 8 9 3 . 








-N^ 



Copyright, 1892. 
Br W. B. SAUNDERS 



LC Control Number 




tmp96 028751 



PREFACE 



Pope says, " Half our knowledge we must snatch, not 
take." If this be true of general knowledge, it is certainly 
true of the knowledge of medicine as it is taught in the schools 
of to-day. In view of this fact, there seems to be a real need 
for books which present their subjects in an assimilable form. 

At the request of many students the author has written this 
book with the hope that it may serve as an outline of Practice 
of Medicine, which shall be enlarged upon by diligent atten- 
dance upon lectures and critical observation at the bedside. 

In its preparation the writings of the following authors 
have been freely consulted : Striimpell, Osier, Fagge, Bristowe, 
Frerichs, Liebermeister, Vierordt, Eichhorst, Wood, Koss, 
Cowers, Sansom, Henry, Tyson, Pepper, Paul, Murrell, Starr, 
Hilton, Duhring, Stelwagon, Van Harlingen, Tilbury Fox, 
Hardaway, Seiler, Cohen, Browne, Jacobi, Bruce, Brunton, 
Charcot, Dujarden-Beaumetz, Pavy, Mitchell, and Trousseau. 

318 South 15th Street, Philadelphia , 
September, 1892. 



CONTENTS. 



Diseases of the Digestive System. 

PAGE 

General Symptomatology — 

The Teeth 17 

The Tongue 17 

Fetor of the Breath 18 

The Appetite . . " . . . . . . .19 

Dysphagia . . . 19 

Vomiting, or Emesis 19 

The Vomit . . .20 

Acidity of the Gastric Contents 20 

Hiccough 21 

Abdominal Pain and Tenderness 21 

The Stools 22 

Abdominal Distention 23 

Diseases of the Mouth, Tonsils, Pharynx, and (Esophagus — 

Stomatitis 23 

Tonsillitis 26 

Hypertrophy of the Tonsils 28 

Pharyngitis . 29 

Spasm of the (Esophagus 32 

Organic (Esophageal Obstruction 32 

Diseases of the Stomach — 

Acute Gastritis 33 

Dyspepsia .34 

Atonic Dyspepsia 35 

jSTervous Dyspepsia 3o 

(v) 



VI 



CONTENTS. 



Catarrhal Dyspepsia 

Gastralgia 

Gastric Ulcer .... 

Gastric Cancer 

Pyloric Obstruction and Dilatation of 

Haematernesis .... 
Diseases of the Intestines and Peritoneum 

Constipation 

Intestinal Colic .... 

Diarrhoea . . . 

Intestinal Catarrh 

Entero-colitis .... 

Dysentery ..... 

Cholera Morbus .... 

Cholera Infantum 

Typhlitis and Appendicitis . 

Intestinal Obstruction ; Ileus 

Animal Parasitic Affections 

Peritonitis ..... 

Ascites 

Diseases of the Pancreas — 

Pancreatic Apoplexy . 

Acute Pancreatitis 

Cirrhosis of the Pancreas . 

Pancreatic Calculi 

Cancer of the Pancreas 
Diseases of the Liver- 
Area of Liver Dulness 

Palpation of the Liver 

Percussion of the Liver 

Jaundice, or Icterus 

Icterus j^eonatorum 

Acholia 

Catarrhal Jaundice 

Biliary Calculi .... 

Hyperemia of the Liver 

Cirrhosis of the Liver . 

Abscess of the Liver . 



the Stomach 



CONTENTS. Vll 

PAGE 

Cancer of the Liver 81 

Amyloid Liver 82 

Hydatid Cysts of the Liver 83 

Acute Yellow Atrophy of the Liver 84 



Diseases of the Kidneys. 

General Symptomatology — 

The Urine 85 

Polyuria J35 

Urea 85 

Lithuria 8G 

Urates 87 

Leucin and Tyrosin 87 

Phosphates 88 

Chlorides 89 

Oxaluria 89 

Urobilinuria .90 

Glucosuria, or Glycosuria 90 

Albuminuria 92 

Acetonuria .......... 93 

Diaceturia and Oxybuturia 93 

Hematuria 93 

Hemoglobinuria . . . . . . . .94 

Indicanuria 94 

Bile 94 

Chyluria . 94 

Pyuria 95 

Diseases of the Kidneys, and Pelvis of the Kidney — 

Renal Hyperemia 95 

Uremia . . . 90 

Acute Nephritis 97 

Chronic Parenchymatous Nephritis 99 

Chronic Interstitial Nephritis ...... 100 

Amyloid Kidney 102 

Renal Calculus 103 

Pyelitis 105 



V1U CONTENTS. 

PAGE 

Hydronephrosis 106 

Floating Kidney 107 

Diseases of the Blood. 

General Symptomatology— 

The Blood 109 

Oligocythemia 109 

Leukocytosis 109 

Poikilocytosis . - 109 

Microcytosis and Macrocytosis ...... 110 

Diminished Haemoglobin 110 

Melaneemia 110 

Lipaemia Ill 

Microoganisms in the Blood Ill 

Anaemia, Scurvy, Addison's Disease, Purpura Hemorrhagica, and 
Haemophilia — 

Anaemia Ill 

Symptomatic Anaemia .111 

Essential, or Primary Anaemia . . . . . 112 

Pernicious Anaemia 11*2 

Chlorosis 113 

Leucocythaemia 114 

Pseudo-leucaemia 11") 

Addison's Disease 115 

Haemophilia 110 

Scurvy 11" 

Purpura Haemorrhagica 117 

Diseases of the Circulatory System. 



General Symptomatology— 

The Apex-beat 

Displacement of the Apex-beat .... 
Changes in the Force and Extent of the Apex-beat 
Abnormal Centres of Pulsation 

Jugular Pulsation 

Praecordial Prominence . . . 



119 
120 
120 
121 
122 
122 



CONTENTS. IX 

PAGE 

Palpation 122 

Percussion 122 

Auscultation 123 

The Intensity of the Heart-sounds 123 

Reduplication of the Heart-sounds ... . 124 

Adventitious Sounds, or Murmurs 124 

Hsemic Murmurs 124 

Pericardial Friction-sounds . . .' . . .125 

The Aneurismal Murmur, or Bruit 125 

The Pulse 125 

Palpitation 128 

Dropsy 129 

General Cyanosis 129 

Diseases of the Pericardium — 

Pericarditis . . . 130 

Hydro-pericardium ........ 133 

Hremo-pericardium 133 

Pneumopericardium "* . . 133 

Diseases of the Heart — 

Endocarditis 133 

Chronic Valvular Affections ...... 135 

Aortic Stenosis, or Aortic Obstruction .... 135 

Aortic Insufficiency, or Aortic Regurgitation . . . 136 

Mitral Stenosis, or Mitral Obstruction .... 136 

Mitral Insufficiency, or Mitral Regurgitation . . . 137 

Tricuspid Stenosis, or Tricuspid Obstruction . . 138 

Tricuspid Insufficiency, or Tricuspid Regurgitation . 138 

Pulmonary Stenosis, or Pulmonary Obstruction . . 138 

Pulmonary Insufficiency, or Pulmonary Regurgitation . 138 

Acute Ulcerative Endocarditis 141 

Acute Myocarditis 142 

Fibroid Heart 142 

Hypertrophy of the Heart . . 143 

Dilatation of the Heart . 144 

Fatty Infiltration of the Heart. 145 

Fatty Degeneration of the Heart . .... 146 

Angina Pectoris 147 



CONTENTS. 



Diseases of the Arteries — 
Aneurism of the Aorta 
Thoracic Aneurism 
Aneurism of the Abdominal Aorta 
Arterio-sclerosis 



PAGE 

148 
149 
151 
151 



Diseases of the Respiratory System. 



G-eneral Symptomatology — 



The Red Nose 


. 153 


Flattening of the Bridge of the Nose 


. 153 


Movement of the Ala? Nasi during Respiration 


. 153 


Nasal Discharge . 


. 153 


The Sense of Smell 


. 153 


Epistaxis 


. 154 


Spasm of the Laryngeal Adductors . 


. 154 


Aphonia, or Loss of Yoice .... 


. 154 


Paralysis of the Laryngeal Muscles . 


. 155 


Dyspnoea 


. 156 


Number of Respirations per Minute . 


. 156 


Cheyne-Stokes, or Tidal-wave Breathing . 


. 156 


Cough 


. 156 


Expectoration 


. 157 




. 158 


Inspection of the Chest ..... 


. 161 


Phthisinoid Chest 


. 161 


Rachitic Chest . 


. 161 


Emphysematous Chest 


. 161 


Local Prominences and Depressions . 


. 162 




. 163 


Palpation . . . . . 


. 163 


Percussion . ■- . 


. 164 


Auscultation 


. 165 


Mensuration . . . . . 


. . . 169 


iseases of the Nose and Larynx— 




Coryza . . 


. 170 


Chronic Nasal Catarrh ..... 


. 171 


Acute Catarrhal Laryngitis .... 


. 173 



CONTENTS. XI 

PAGE 

Chronic Laryngitis 174 

Spasmodic Croup 176 

Membranous Croup 177 

Laryngismus Stridulus . 179 

(Edema of the Larynx 181 

Diseases of the Lungs — 

Bronchitis 182 

Dilatation of the Brouchial Tubes 189 

Asthma 191 

Hay Asthma 194 

Pulmonary Emphysema 195 

Haemoptysis 198 

Pulmonary Apoplexy 199 

Congestion of the Lungs . '..... 200 

Croupous Pneumonia 202 

Catarrhal Pneumonia ........ 207 

Chronic Interstitial Pneumonia 211 

Gangrene of the Lung 212 

Abscess of the Lung 213 

(Edema of the Lungs 214 

Pulmonary Collapse , 215 

Pulmonary Tuberculosis 216 

Diseases of the Pleura- 
Pleurisy 223 

Hydrothorax . . 227 

Pneumothorax . . . 227 

Hemothorax 229 



Acute Infectious Diseases. 

Fever 230 

Period of Incubation 233 

Date at which Hashes Appear 233 

Protection from Future Attacks 234 

Periodic Remissions or Intermissions in the Fever . . 234 

Fevers Associated with Jaundice 235 

Termination by Crisis ....... 235 

Subnormal Temperature 235 



XI 1 CONTENTS. 

PAGE 

Simple Continued Fever . . . . . . . 236 

Typhoid Fever . . 237 

Typhus Fever 243 

Relapsing Fever 245 

Cerebro-spinal Fever . 247 

Malarial Fever 250 

Scarlet Fever . 256 

Measles 260 

Rotheln 262 

Smallpox 263 

Varicella 266 

Vaccinia 267 

Erysipelas 268 

Yellow Fever . . . 270 

Acute General Tuberculosis 272 

Diphtheria 274 

Whooping-cough 278 

Influenza 280 

Mumps ' 281 

Cholera 283 

Tetanus 286 

Dengue 288 

Hydrophobia 288 

Constitutional Diseases. 

Rheumatic Fever 290 

Chronic Rheumatism 294 

Muscular Rheumatism 295 

Gout *. . 297 

Rheumatoid Arthritis . . . • . . . 300 

Rickets 302 

Lithremia * . .303 

Diabetes 304 

Diabetes Insipidus 308 



CONTENTS. Xll 1 



Diseases of the Nervous System, 
Disturbances of Motion. 

PAGE 

Paralysis 310 

Irregular Paralysis 310 

Monoplegia 311 

Hemiplegia . 311 

Paraplegia 31-2 

Convulsions 313 

Epileptiform Convulsions 313 

Tetanic Convulsions . . 314 

Hysteroidal Convulsions 314 

Local Convulsions . 315 

Saltatory Spasm 315 

Salaam Convulsions 315 

Choreiform Movements 315 

Athetosis 31(3 

Tremors 317 

The Gait . . .317 

TheEeflexes 318 

Paradoxical Contraction 320 

Disturbances of Sensation. 

Anaesthesia 320 

Hemianesthesia 320 

Monanesthesia 320 

Paranesthesia 320 

Hyperesthesia 322 

Paresthesia 322 

Neuralgia . 322 

Muscular Sensibility ........ 322 

Muscular Sense 322 

Disturbances of Nutrition. 

Muscular Atrophy 323 

Reaction of Degeneration 323 



XIV CONTENTS. 

PAGE 

Arthropathies 324 

Myxoedema 324 

Ulceration Resulting from Perverted Nutrition . . 325 

Disturbances of Consciousness. 

Coma 325 

Trance 327 

Somnambulism 327 

Ecstasy 327 

Catalepsy 327 

Disturbances of the Special Senses. 

The Eye 327 

The Ear 327 

Psychical Disturbances. 

Delusion 328 

Illusion 329 

Hallucination . . 329 

Imperative Conception 329 

Morbid Impulse 329 

Delirium 329 

Diseases of the Brain, Cord. Serves, and Muscles. 

Tuberculous Meningitis 331 

Simple Leptomeningitis 333 

Chronic Pachymeningitis . . ... . . . 333 

Hemorrhagic Pachymeningitis ...... 334 

Hydrocephalus . . . 334 

Paretic Dementia . . 336 

Cerebral Paralysis of Children 338 

Cerebral Hyperemia 339 

Cerebral Anaemia 340 

Cerebral Hemorrhage 341 

Obstruction of the Cerebral Arteries .... 345 

Cerebral Softening ........ 346 



CONTENTS. XV 

PAGE 

Morbid Growths in the Brain . ....... 347 

Abscess of the Brain 350 

Cretinism 351 

Spinal Leptomeningitis ....... 352 

Chronic Spinal Pachymeningitis 353 

Acute Myelitis . 354 

Chronic Myelitis ........ 356 

Sclerosis of the Spinal Cord 357 

Locomotor Ataxia 357 

Primary Spastic Paraplegia 360 

Amyotrophic Lateral Sclerosis 361 

Ataxic Paraplegia 361 

Disseminated Cerebro-spinal Sclerosis .... 361 

Hereditary Ataxia . . 362 

Syringo-myelia ......... 363 

Acute Anterior Poliomyelitis 363 

Progressive Muscular Atrophy 365 

Bulbar Paralysis 367 

Acute Ascending Paralysis 367 

Caisson Disease 368 

Idiopathic Muscular Atrophy 369 

Pseudo-hypertrophic Paralysis 370 

Neuralgia 371 

Migraine 374 

Headache 375 

Neuritis 379 

Multiple Neuritis 381 

Sciatica 382 

Facial Paralysis 383 

Epilepsy 385 

Aphasia 387 

Vertigo 389 

Meniere's Disease 390 

Hysteria 391 

Neurasthenia 395 

Chorea 396 

Paralysis Agitans 398 

Artisan's Cramp 400 



XVI CONTENTS. 

PAGE 

Tetany 400 

Thomsen's Disease 401 

Exophthalmic Goitre 402 

Raynaud's Disease 403 

Acute Angio-neurotic (Edema 404 

Myxoedema 404 

Facial Hemi-a trophy 405 

Acromegalia 405 

Sunstroke 406 

Intoxications — 

Alcoholism 408 

Opium-poisoning 410 

Chronic Lead-poisoning 411 

Chronic Mercurial Poisoning 412 

Chronic Arsenical Poisoning 413 

Diseases of the Skin and its Appendages. 

G-eneral Symptomatology — 

The Color of the Skin 414 

Hardness, or Induration of the Skin 415 

(Edema, or Dropsy of the Subcutaneous Tissues . . 416 

Glossy Skin 416 

Enlargement of the Superficial Veins . .... 416 

Cutaneous Emphysema ....... 416 

Abnormal Conditions of the Kails 417 

Cutaneous Eruptions — 

Macules 417 

Purpuric Spots 418 

Vesicles '"-.'. . . 420 

Blebs, or Bulla? . . .422 

Pustules 422 

Papules 424 

Tubercles 425 

Wheals, or Pomphi 426 

Crusts . . _ 426 

Scales 428 

Ulcers 428 



CONTENTS." XV11 

PAGE 

Diseases of the Sweat-glands — 

Anidrosis 430 

Hyperidrosis 430 

Bromidrosis 431 

Chromidrosis . . . 431 

Sudamen 431 

Functional Diseases of the Sebaceous Glands — 

Seborrhea 432 

Comedo 433 

Milium 434 

Steatoma 435 

Inflammatory Diseases of the Skin — 

Erythema Simplex .... .... 435 

Erythema Intertrigo . 436 

Erythema Nodosum 436 

Erythema Multiforme 436 

Urticaria ;;";-.. 437 

Herpes Simplex 438 

Herpes Zoster . 439 

Herpes Iris 440 

Acne Vulgaris 440 

Acne Rosacea . . . 442 

Furunculus 443 

Carbunculus . . . 444 

Psoriasis 444 

Eczema • . . 446 

Lichen Ruber and Lichen Planus 449 

Prurigo 450 

Dermatitis Herpetiformis 450 

Dermatitis 451 

Ecthyma 453 

Pemphigus . , 454 

Impetigo .455 

Impetigo Contagiosa 456 

Miliaria . . . 457 

Atrophic Affections of the Skin — 

Albinism 458 

B 



XVI11 CONTENTS. 

PAGE 

Vitiligo 458 

Atrophic A flections of the Hair and Nails . . . 459 

Hypertrophic Affections of the Skin — 

Lentigo .......... 464 

Chloasma . . 464 

Keratosis Pilaris 465 

Molluscum Epitheliale 466 

Callositas 466 

Clavus ........... 467 

Cornu Cutaneum 468 

Verruca 468 

N"aevus 469 

Ichthyosis 469 

Hypertrophic Affections of the Hair and Nails . . 470 

Scleroderma . . . . 470 

Morphcea 471 

Elephantiasis 471 

Dermatolysis ......... 472 

New Growths of the Skin — 

Keloid 473 

Fibroma 473 

Angioma 474 

Xanthoma 474 

Lupus Erythematosa ........ 475 

Lupus Vulgaris 476 

Syphilis Cutanea 478 

Leprosy . . . . . . . . . . 480 

Epithelioma 482 

Ainhum 483 

Neuroses of the Skin— 

Dermatalgia . . . 483 

Pruritus . .484 

Parasitic Affections of the Skin — 

Tinea Tricophytina 485 

Tinea Versicolor 487 

Tinea Favosa . ■ . 488 

Scabies 488 

Pediculosis 489 



DISEASES 



DIGESTIVE SYSTEM 



THE TEETH AND GUMS. 

Delayed dentition, and the eruption of badly-formed 
teeth, often result from rickets or congenital syphilis. 

Caries of the teeth results from many conditions ; notably, 
an unnatural softness of the teeth, lack of cleanliness, dys- 
pepsia, the use of certain drugs, and diabetes. 

Hutchinson's teeth. — The lateral incisors of the upper jaw 
are pegged, and the central incisors of the same jaw have 
convex sides, and crescentic notches on their cutting edges. 
These peculiarities indicate hereditary syphilis, and are noted 
only in the permanent teeth. 

A blue line on the gums near the insertion of the teeth 
usually indicates chronic lead poisoning. Copper and silver 
poisoning occasionally produce similar lines. 

Spongy, bleeding gums are often associated with scurvy. 
Swelling of the gums with tenderness and salivation is indica- 
tive of mercurial poisoning (ptyalism). 

THE TONGUE. 

Fur on the tongue. — This consists for the most part of ac- 
cumulated epithelial cells, particles of food, and microorgan- 
isms, and results from an elevation of temperature or from 
disturbed innervation. 

2 



18 DISEASES OF THE DIGESTIVE SYSTEM. 

A light, uniform coat is often noted in health, particularly in 
those who sleep with the mouth open. Other causal condi- 
tions are : — 

(1) In febrile diseases. 

(2) In dyspepsia. 

(3) In catarrhal conditions of the nose and throat. 
Circumscribed furring often indicates local disturbance, as a 

jagged tooth or tonsillitis. 

Unilateral furring may result from disturbed innervation, as 
in conditions affecting the second and third branches of the 
fifth nerve. It has been noted in neuralgia of those branches, 
and in fractures of the skull involving the foramen rotundum. 

The dry, brown, and fissured tongue is noted in low fevers, as 
typhoid fever, typhoid pneumonia, typhoid dysentery. 

A red, beefy tongue is noted in certain febrile diseases, as 
typhoid fever and scarlet fever, and in diabetes. 

The {t strawberry tongue" is characterized by a white fur, 
through which project bright red and prominent papilla?. It 
is seen in the early stage of scarlet fever. 

A gray-coated and flabby tongue, with an oval bare spot in 
the centre, which is red and glossy, is sometimes seen in chil- 
dren, and is indicative of gastro-intestinal catarrh, or "mucous 
disease." (Starr.) 

Tremor of the Tongue. 

Trembling of the tongue is noted in many conditions ; it is 
peculiarly marked in low fevers (typhoid), in alcoholism, and 
in paretic dementia. 

Scars on the Tongue. 

Scars on the tongue often result from syphilitic lesions, or 
from the tooth wounds of epilepsy. 

FETOR OF THE BREATH. 

This is often due to local inflammation, as chronic rhinitis, 
tonsillitis, etc. ; to the retention of decomposing food, to caries 



VOMITING, OR EME8IS. 19 

of the teeth, to certain lung diseases, especially gangrene and 
bronchiectasis, to dyspepsia, and to the ingestion of certain 
foods or drugs. 

THE APPETITE. 

Boulimia, or inordinate appetite, is a common symptom in 
nervous dyspepsia, diabetes, worms, and in certain insanities, 
notably in paretic dementia. 

Anorexia, or loss of appetite, is a symptom common to many 
conditions. 

Pica is a craving for unnatural articles of food, and is noted 
particularly in chlorosis, insanity, pregnancy, and worms. 

DYSPHAGIA. 

Dysphagia, or difficult swallowing, may result from : (1) 
Local inflammations. (2) Stricture of the oesophagus, spas- 
modic or organic. (3) Paralysis, local, as in diphtheritic 
paralysis ; or centric, as in bulbar disease. 

VOMITING, OR EMESIS. 

Etiology. — (1) Toxic, from ptomaines, drugs, uraemia, 
and the specific fevers. (2) Centric disease, as cerebral 
tumors and meningitis ; this type is often unaccompanied 
with nausea, and does not relieve the associated headache. 
(3) Diseases of the stomach, as ulcer, cancer, dilatation, dys- 
pepsia, etc. (4) Reflex, as from pregnancy, uterine or ovarian 
disease, irritation of the fauces, worms, biliary colic, etc. (5) 
Intestinal obstruction, this is often fecal. (6) Disturbed cere- 
bral circulation, as in swinging and sea-sickness. (7) Certain 
nervous affections, as hysteria, migraine. (8) Periodic vomit- 
ing may be in itself a neurosis, or may be associated with the 
gastric crises of locomotor ataxia. (9) ^Esophageal vomiting 
results from obstruction, and the vomit is alkaline in reaction. 



20 DISEASES OF THE DIGESTIVE SYSTEM. 



THE VOMIT. 

Watery, or mucous vomit, is noted in chronic gastritis, in 
certain forms of nervous dyspepsia, and after persistent emesis, 
as in cholera. 

Bilious, or green vomit, is not diagnostic of any special con- 
dition ; it may occur in any case where vomiting and straining 
are continued. 

Bloody vomit (Herniate me sis). — For cause, see page 00. 
When present in large amount, it can usually be recognized 
by the unaided eye ; small amounts may be detected by the 
microscope, spectroscope, or by chemical tests. 

Test for blood. — Evaporate some of the filtered coffee-grounds 
vomit in a watch-glass, scrape oif some of the dried material ; 
add a trace of finely -pulverized salt ; place the mixture on an 
object-glass, and cover. Allow one or two drops of glacial 
acetic acid to run under, and again evaporate ; when dry allow 
one or two drops of distilled water to flow under to dissolve 
the crystals of salt. Under the microscope minute brown 
rhombic crystals of hsematin appear. 

Purulent vomit may result from the rupture of an abscess 
into the oesophagus or stomach, or from phlegmonous gastritis. 

Fecal vomit (stercoraceous) is indicative of intestinal obstruc- 
tion. 

Profuse vomit. — The ejection of large quantities of frothy 
fermented material is highly significant of gastric dilatation. 

Vomiting without nausea, distress, or other phenomena occurs 
in certain neuroses of the stomach, in hysteria, uraemia, and in 
brain disease, as tumor, or as a precursor of apoplexy. 

ACIDITY OF THE GASTRIC CONTENTS. 

Normal acidity is due to hydrochloric acid, but other acids 
are frequently formed during the digestive process, namely : 
lactic, butyric, and acetic acids. 

For chemical examination, the vomit should be preserved 
and filtered, or, which is far better, the contents of the stomach 
should be drawn off after a test-meal and filtered. 



ABDOMINAL PAIN AND TENDERNESS. 21 

Tests for free hydroch loric acid. — ( 1 ) Paper stained with a solu- 
tion of congo red turns blue. Not very reliable. (2) Paper 
stained with an alcoholic solution of oo-tropseolin turns from 
a yellowish-brown to deep brown or red. (3) Giinzburg's 
test, very reliable. 

$. Phloroglucin, 1 part ; 
Vanillin, 1 part ; 
Absolute alcohol, 30 parts. 
Add one or two drops to a similar quantity of the filtrate con- 
tained in a porcelain dish, heat gently, and if free hydrochloric acid 
is present a rose-red color develops. 

Hyperacidity. — This condition is especially noted in ulcer 
of the stomach, and in certain forms of nervous dyspepsia. 

Subacidity or inacidity occurs (1) in certain nervous affec- 
tions, as in some forms of nervous dyspepsia, hysteria, and 
neurasthenia. (2) In extreme ansemia. (3) In gastric catarrh. 
(4) In gastric cancer. (5) In most febrile diseases. (6) In 
pyloric obstruction and gastric dilatation. 

HICCOUGH. 

Hiccough, or singultus, results from a clonic spasm of the 
diaphragm, and is often noted as a temporary condition after 
eating or drinking. Persistent hiccough is sometimes present 
in extreme exhaustion following acute or chronic diseases. It 
results from irritation of the phrenic nerve, as from the pres- 
sure of a thoracic aneurism. It may be reflex from stomachic, 
hepatic, intestinal, or peritoneal disease. It may be due to 
hysteria. 

ABDOMINAL PAIN AND TENDERNESS. 

Diffuse abdominal tenderness is noted in peritonitis, in hys- 
teria, and in rheumatism of the abdominal muscles. 

Persistent abdominal pain results from the various visceral 
diseases, chronic peritonitis, abdominal aneurism, and disease 
of the spinal vertebrae. 

Colic is a painful spasm of a mucous canal. The common 
varieties are — biliary, intestinal, renal, uterine, and pancreatic. 



22 DISEASES OF THE DIGESTIVE SYSTEM. 

Painful defecation results from constipation, anal fissure, 
dysentery, piles, ulceration, stricture, prolapse of the rectum, 
and inflammatory conditions of neighboring organs, as the 
uterus or prostate gland. 

THE STOOLS. 

Blood in the Stools (Entrorrhagia or Melcena). 

The blood is nearly normal in appearance after profuse 
hemorrhages, or when it has been quickly discharged, as in 
piles and fissure. Retained blood imparts a black or tarry 
appearance to the stools. 

Melsena results from: (1) Traumatism. (2) Acute in- 
flammation of the bowels, as in enteritis and dysentery. (3) 
Obstructed circulation, as in chronic heart and liver disease. 
(4) Vicarious menstruation. (5) Blood dyscrasia, as in scurvy, 
purpura, infectious fevers, etc. (6) Rupture of an aneurism. 
(7) Ulcers in the intestines, as simple duodenal ulcer, typhoid, 
dysenteric, tubercular, or malignant ulcers. (8) Intussuscep- 
tion. (9) The passage of blood from the stomach in haema- 
temesis. (10) Piles, fissure, fistula. 

Watery, or serous stools are noted in choleraic diseases, in 
nervous -diarrhoea, in the colliquative diarrhoea which termi- 
nates wasting diseases, in severe enteritis, in corrosive poison- 
ing, as arsenic, antimony. 

Green stools may result from an excessive amount of bile. 
They are also common in the diarrhoeas of young children, 
and in these cases the green color may be due to bacterial 
growth. (Hay em.) 

Black stools may follow intestinal hemorrhage, and the . use 
of certain drugs, as charcoal, bismuth, iron, tannin, etc. 

Bed stools usually indicate blood, but they may be tinged red 
after the administration of hsematoxylin (logwood). 

Mucous stools are noted in intestinal catarrh, particularly 
when the lower bowel is affected, as in entero-colitis and dys- 
entery. 

Fatty stools result from the ingestion of large quantities of 
fats, from the absence of bile, and from chronic pancreatic 



STOMATITIS. 23 

Purulent stools result from fistula in ano, dysenteric, syphi- 
litic, or malignant ulceration, or the rupture of abscesses into 
the bowel, as prostatic and pelvic abscesses. 

Li-enteric stools. — Stools which contain much undigested food 
are noted in inflammatory conditions of the stomach and upper 
bowel. 

ABDOMINAL DISTENTION. 

Causes. — (1) Enlargement of the various organs from 
tumors or other causes. Recognized by the history, irregular 
enlargement, and special symptoms referable to the organ af- 
fected. (2) Ascites. Recognized by movable dulness with 
superincumbent tympany, and fluctuation. (3) Tympanites. 
Recognized by universal tympany on percussion. (4) Preg- 
nancy. Recognized by suppression of menses, morning emesis, 
pigmentation of mammary areola, softening of the cervix, in- 
termittent uterine contractions, etc. (5) Distention of the 
bladder. Recognized by the history, location of dulness, and 
results of catheterization. 

STOMATITIS. 

Definition. — Inflammation of the mouth. 

Etiology. — (1) Mechanical, chemical, thermal, or parasitic 
irritation. (2) Mercurial poisoning. (3) Cachectic states, as 
in phthisis, cancer, and diabetes. (4) It is most commonly 
seen in young children in association with gastro-intestinal 
disturbances, brought about by artificial feeding, warm weather, 
and bad hygienic surroundings. 

Varieties. — (1) Catarrhal. (2) Aphthous. (3) Ulcerative. 
(4) Parasitic (thrush). (5) Gangrenous. (6) Mercurial. 

General Symptoms. — Heat and pain in the mouth, in- 
creased flow of saliva, fetor of the breath, restlessness, languor, 
disinclination to nurse, and perhaps some fever. 

Catarrhal Stomatitis (Simple stomatitis). 

Symptoms. — General symptoms of stomatitis, and, on in- 
spection, a diifuse red swelling of the mucous membrane. 

Treatment. — Good hygienic conditions. Keep the month 



24 DISEASES OF THE DIGESTIVE SYSTEM. 

clean. Employ a weak solution of boric acid or of chlorate 
of potassium as a wash. 

Aphthous Stomatitis (Follicular stomatitis, Vesicular stom- 
atitis'). 

Symptoms. — General symptoms of stomatitis, and, on in- 
spection, numerous small, round vesicles on the cheeks, lips, 
and tongue ; these vesicles soon break, and leave little, shallow 
ulcers with a red areola. 

Prognosis. — Good. 

Treatment. — Sterilize the milk. Xurse at regular inter- 
vals. Wash the mouth with a clean linen cloth. Correct 
any gastric disturbance. Use locally : — 

fy Acid, boric, gr. x-xx ; 

Glycerinse, f^ss ; 
Aqua 1 , q. s. ad f^ij. — M. 
Chlorate of potassium (gr. xx-xxx) may be substituted for the 
boric acid. 

Ulcerative Stomatitis. — This is thought by some to be an 
infectious disease, because it often occurs in epidemics, and 
attacks both children and adults when congregated and sub- 
jected to bad hygienic conditions. 

Symptoms. — General symptoms of stomatitis. 

Inspection.— The gums of the lower jaw are chiefly affected. 
They are swollen, red, and spongy. Linear ulcers, with gray, 
sloughing bases soon form, and may extend to the cheek. The 
glands under the jaw are swollen. In severe cases loosening 
of the teeth and necrosis of the bone may follow. 

Peogxosis. — Guardedly favorable. 

Treatment. — Correct the hygiene. Tonic doses of quinine 
by the stomach or rectum are indicated. Touch the ulcers 
with nitrate of silver, apd use as a mouth-wash a solution of 
chlorate of potassium or peroxide of hydrogen. 

Parasitic (Thrush, Muguef). 

Exciting Cause. — Saccharomyces albicans. 

Symptoms. — General symptoms of stomatitis, and, on in- 
spection, numerous milk-white elevations which, on removal, 
leave a raw surface. The disease may extend to the pharynx, 
oesophagus, and larynx. Microscopic examination reveals the 
fungus. 



STOMATITIS. 25 

P rognosis. — Good. 

Treatment. — Correct the hygiene. Treat any gastric dis- 
turbance. Tonics are often indicated. Locally, borax is of 
value, and may be used in the following mixture: — 

fy Sodii borat. , £j ; 
Glyeerinse, £ij ; 
Aquae, 3yj.— M. 
Sig. — Apply several times daily by means of a camel's-hair brush. 

Gangrenous Stomatitis (Cancrum oris, Noma). — This form 
is usually seen in debilitated children between the ages of two 
and six years, and usually follows one of the specific fevers, 
especially measles and whooping-cough. 

Symptoms. — The general symptoms of stomatitis are 
marked. 

Inspection. — The cheek is the part affected. Externally, 
it is swollen, hard, red, and glazed ; internally, there is noted 
an irregular, sloughing ulcer. 

Complications. — Perforation, septicaemia, lobular pneu- 
monia from aspirated sloughs, and diarrhoea from the swal- 
lowing of fetid material. 

Prognosis. — Grave. Death is common from exhaustion 
or complications. Recovery is often attended with deformity. 

Treatment. — Good hygiene, alcoholic stimulants, nutri- 
tious food, tonics like iron and quinine. 

Locally. — Evert the cheek and apply the actual cautery, or 
pack the surrounding parts with oiled lint, apply to the ulcer 
strong nitric acid, and subsequently neutralize with bicarbo- 
nate of sodium. As a mouth-wash, peroxide of hydrogen is of 
extreme value. 

Mercurial Stomatitis (Ptyalism). — This form of stomatitis 
is seen in artisans who work in mercury, after the administra- 
tion of very large doses of mercurials, and after the adminis- 
tration of small doses when there has been an unnatural 
susceptibility. 

Symptoms. Premonitory Symptoms. — Tenderness of the 
gums, manifested by bringing the teeth forcibly together ; 
redness of the gums near the insertion of the teeth, a metallic 
taste, and an increase of saliva. 



26 DISEASES OF THE DIGESTIVE SYSTEM. 

Later Symptoms. — Profuse salivation, fetor of breath, red- 
ness, swelling, and tenderness of the gums. The tongue may 
be similarly affected and protrude from the mouth. In severe 
cases ulceration of the mucous membrane, loss of teeth, and 
necrosis of the jaw result. 

Treatment. — Use astringent mouth-washes. Employ 
iodide of potassium in small doses to eliminate the mercury. 
Opium may be required at night to allay distress. Belladonna 
aids in arresting the secretion. 

TONSILLITIS. 

(Amygdalitis.) 

Etiology. — Tonsillitis occurs at all ages, but it is particu- 
larly common in the young. 

The rheumatic diathesis exerts a predisposing influence. 
Exposure to cold and wet usually excites it, and such exposure 
is very effective when the system is debilitated, or the throat 
is congested from improper use of the voice. Impure air, as 
the effluvium from foul drains or sewers, sometimes excites it. 

Varieties. — (1) Simple, or catarrhal. (2) Follicular, or 
lacunar. (3) Phlegmonous (quinsy). 

Symptoms.— Pain in the throat increased by swallowing 
and talking ; marked tenderness beneath the angles of the jaw ; 
and fever with its associated phenomena ; in severe forms the 
temperature is quite high, 104° or 105°. 

In the catarrhal form the tonsils are uniformly swollen, red, 
and covered with tenacious mucus. 

In the follicular form the tonsils are red and swollen, and 
present little yellow spots on their surfaces. These spots are 
found to be plugs of degenerated epithelium which are retained 
in the crypts on account of the swelling and occlusion of their 
outlets. These plugs are often expectorated during convales- 
cence as offensive cheesy pellets. 

In the -phlegmonous form the tonsils are extremely swollen, 
often so much that they almost meet, the pain is intense and 
of a throbbing character. One gland soon becomes larger 
than the other, softens, fluctuates, and turns yellow from sup- 
puration. Swallowing is almost impossible, the voice is lost, 
and breathing is difficult. 



TONSILLITIS. 27 

Diagnosis. — In children tonsillitis may resemble scarlet 
fever, especially when the former is associated with an acci- 
dental rash. 

Scarlet Fever. — History of contagion, onset with vomiting, 
a punctated red rash, " strawberry" tongue, albuminuria, and 
pulse too rapid to be proportionate to the fever. 

Diphtheria. — The follicular form resembles diphtheria, but 
in the latter there is a false membrane, not only on the tonsils 
but on surrounding parts, and its removal leaves behind a 
raw surface. The history of contagion, the rapid, weak pulse, 
the marked swelling of the submaxillary glands, albuminuria, 
and the Klebs-Loffler bacillus, detected by cultivation, will 
also indicate diphtheria. 

Prognosis. — Favorable ; even in grave cases rupture of the 
abscess occurs when death seems imminent. Suffocation from 
rupture during sleep, and death from ulceration of the carotid 
artery are extremely rare terminations. 

Treatment. — Rest, light diet, and protection. In the 
beginning, salicylate of sodium (gr. xx thrice daily) may be 
given to shorten the attack. The ammoniated tincture of 
guaiacum (3\j every tw T o hours) is a very efficient remedy. 
The benzoate of sodium is also highly recommended : — 

I£ Sodii benzoat., 3j-^iv ; 
Glycerin., 

Elix. calisay., aa fjj. — M. 
Sig. — A teaspoonful every hour or two. 

In some cases quinine (gr. v. thrice daily) with small doses 
of the tincture of aconite and the tincture of belladonna is 
an efficient remedy. 

In severe cases opium is often required to relieve pain and to 
produce sleep. 

Local Treatment (Internal). — Pellets of ice give much relief. 
The following remedies are efficient : Solutions of nitrate of 
silver, dry bicarbonate of sodium, guaiac lozenges (gr. ij), 
saturated ethereal solution of iodoform. Or : — 

I£. Potass, chlor. , gr. xx-xxx ; 
Tinct. ferri chlor., 
Glycerin., aa f^ss ; 
Aqute, q. s. ad f|ij.— M. 
Sig.— Apply several times daily with a camel's-hair brush. 



28 DISEASES OF THE DIGESTIVE SYSTEM. 

When the glands are very much swollen scarification will 
lessen the pain and often shorten the attack. When fluctua- 
tion is detected the tonsil should be incised with a guarded 
bistoury. 

External Applications. — An ice-bag, a poultice, or iodine. 

HYPERTROPHY OF THE TONSILS. 

Etiology. — Childhood, the rachitic and tubercular dia- 
theses, and repeated attacks of acute tonsillitis are the predis- 
posing causes. It may arise without obvious cause. 

Pathology. — It may be a true hypertrophy, but in most 
instances either the glandular structure or the connective 
tissue predominates ; and the firmness of the gland increases 
in proportion to the overgrowth of the latter. The follicles 
are often dilated, and filled with cheesy material which results 
from the accumulation of fatty-degenerated epithelium. Naso- 
pharyngeal catarrh and adenoid growths in the naso-pharynx 
are often associated conditions. 

Symptoms. — Difficult swallowing, mouth-breathing, snor- 
ing during sleep, a thick voice with a nasal twang to it, and 
malnutrition. Sufferers are very prone to acute attacks of 
catarrh of the nose and throat. In severe cases, from inter- 
ference with breathing, the chest assumes the rachitic type — 
that is, flattened at the sides and base and prominent over the 
sternum. 

Prognosis. — Favorable under prolonged and careful treat- 
ment. 

Treatment. General Treatment. — Build up the tone of the 
patient by frequent bathing with salt water, followed by fric- 
tion, light gymnastics, deep breathing, and by the use of 
nutrient tonics such as cod-liver oil, hypophosphites, and 
iodide of iron. 

Local Treatment. — A solution of nitrate of silver, or Lugol's 
solution (liquor, iodinii comp.), may be applied frequently to 
the tonsils ; or dilute acetic acid (gtt. ij.) or a dilute solution 
of iodine (gtt. ij.) may be injected into the tonsils. When the 
glands are very large they should be removed by the tonsil- 
litome, scissors, or galvano-cautery. Pharyngeal adenoids 



PHARYNGITIS. 29 

should likewise be removed by the finger-nail or curette 
while the patient is under the influence of some general anaes- 
thetic, or after the parts have been treated with cocaine. 

PHARYNGITIS. 

Acute Pharyngitis {Acute " sore throat" Simple angina). 

Definition. — An acute catarrhal inflammation of the 
mucous membrane of the pharynx, soft palate, and uvula, and 
frequently associated with tonsillitis and laryngitis. 

Etiology. — Exposure to cold and wet, especially when the 
system is debilitated or the throat is congested from improper 
use of the voice. It may be rheumatic in origin. It may be 
excited by local irritants, such as hot drinks or the inhalation 
of noxious gases. 

Exposure to infectious fevers, like scarlatina and measles, 
may be followed by simple pharyngitis. 

Symptoms. — Chilliness and slight fever with its associated 
phenomena; soreness in the throat, painful deglutition, a sen- 
sation of dryness or tickling, with a hacking cough ; stiffness 
and tenderness of the muscles of the neck. Extension to the 
larynx may cause hoarseness ; to the ear, through the Eusta- 
chian tube, deafness. Inspection reveals a red and swollen 
mucous membrane. 

Varieties. — (1) Simple; recognized by the above symp- 
toms. (2) Rheumatic ; recognized by the history, intense pain, 
and stiffness of the muscles, without much change in the local 
appearance. (3) Follicular; the mucous membrane is red, 
swollen, and covered with whitish spots which represent re- 
tained secretion in the inflamed follicles. (4) Infectious pharyn- 
gitis is the form associated with the infectious fevers. 

Prognosis. — Favorable. 

Treatment. — Light diet and avoidance of exposure. Hot 
drinks, followed by Dover's powder (gv. x), and a saline purge 
will sometimes abort it. 

Tincture of aconite (gtt. ij) with tincture of belladonna (gtt. 
v) every two hours is sometimes useful. In the rheumatic 
form the salicylate or benzoate of sodium is very efficient. 



30 DISEASES OF THE DIGESTIVE SYSTEM. 

Ill simple angina Pepper recommends : — 

]£ Potass, chlorat. , ^iss-ij ; 
Potass, bromid., 5ss; 
Ext. belladonnas gr. iij-v ; 
Syr. limonis, f.^j ; 
Syrupi, q. s. ad f^iv. — M. 
Sig. — Teaspoonful thrice daily. 

Local Remedies. — A steam spray, pellets of ice, a gargle 
of chlorate of potassium (gr. x to f 3j), the application of a 
solution of nitrate of silver (gr. v to f5J), or lozenges of 
cocaine, chloride of ammonium, or chlorate of potassium. 

Chronic Pharyngitis. 

Etiology. — Chronic " sore throat" usually results from re- 
peated acute attacks, improper use of the voice, or the con- 
tinuous action of irritants, like tobacco smoke. 

Varieties. — (1) Hypertrophic. (2) Atrophic. (3) Ulcer- 
ative. (4) Phlegmonous. 

Symptoms. — The voice is husky and its use is followed by 
distress ; secretion is increased so that there is a constant desire 
to clear the throat ; disagreeable sensations, as fulness, tickling, 
and the like, are frequently noted. 

In the hypertrophic form (granular sore throat, clergyman's 
sore throat, chronic follicular pharyngitis) the mucous mem- 
brane is thick, swollen, traversed by dilated veins, and 
studded with numerous elevations which are composed of dis- 
tended follicles and overgrown lymphatic tissue. 

In the atrophic form (Pharyngitis Sicca), the mucous mem- 
brane is pale, smooth, glossy, and dry. 

Ulcerative Pharyngitis. — Ulceration may be due to simple 
inflammation, syphilis, tuberculosis, cancer, lupus. 

Phlegmonous Pharyngitis {Retropharyngeal abscess). — Sup- 
purative inflammation of the retropharyngeal connective tissue 
may occur as a sequel to one of the infectious fevers, or may 
be due to caries of the cervical vertebrae, or to the impaction 
of a foreign body. 

It may be recognized by sore throat, weak voice, difficult 
deglutition, and the results of a digital examination. 

Treatment. — Chronic pharyngitis does not result so much 



STENOSIS OF THE (ESOPHAGUS. 31 

from excessive use of the voice as from its improper use, aud 
until this is corrected no treatment will be successful. Pa- 
tients should be instructed to expel sounds by the aid of the 
diaphragm and abdominal muscles, instead of the muscles of 
the throat and larynx. The habit of hawking and scraping 
to clear the throat must be rigidly interdicted. The patient 
must guard against mouth-breathing. Sponging the neck 
night and morning, first with tepid, then with cold water, will 
render the throat less sensitive. The general health will re- 
quire attention, and such tonics as iron, quinine, strychnine 
may be very useful. 

Local treatment. — The naso-pharynx should be kept clean 
by frequent spraying or douching with some antiseptic solu- 
tion like the following : — 

I$l Sodii bicarb., 

Sodii biborat., aa gr. xx ; 

Acid, carbolic, gtt. vj ; 

Glycerin., f^vj ; 

Aquae, q. s. ad f^vj. — M. (Dobell.) 

The nasal chambers should be inspected and any existing 
disease treated. 

Astringent applications are often useful ; solutions of nitrate 
of silver, five or ten per cent., sulphate of zinc, or tannic 
acid, ten to twenty per cent., may be employed for this pur- 
pose. Lymphatic hypertrophies should be removed by the 
galvano-cautery. 

Retropharyngeal abscesses will require evacuation and treat- 
ment directed to the cause. 

Ulcerative pharyngitis will require appropriate constitu- 
tional treatment, and such local remedies as nitrate of silver, 
iodoform, nitric acid, etc. 



STENOSIS OF THE (ESOPHAGUS. 

Varieties. — (1) Functional obstruction, due to spasm 
(cesophagismus). (2) Organic obstruction. 



32 DISEASES OF THE DIGESTIVE SYSTEM. 



SPASM OF THE OESOPHAGUS. 

Etiology. — Female sex ; nervous temperament ; hysteria ; 
reflex irritation. It may occur as a symptom of hydrophobia, 
tetanus, and organic oesophageal obstruction. 

Symptoms of Simple (Esophageal Spasm. — Paroxysmal 
dysphagia, often associated with a sense of constriction in the 
chest ; little or no loss of flesh. An oesophageal bougie can 
be passed without much difficulty. 

Diagnosis. — The age and sex of the patient, the parox- 
ysmal character of the obstruction, the ability to pass a bougie, 
the absence of wasting, and the absence of any other cause, 
will serve to separate it from organic obstruction. 

Prognosis. — Good for life, but indefinite as regards dura- 
tion. 

Treatment. — Search for some exciting cause and remove 
it when possible. The treatment is largely dietetic, hygienic, 
and moral. Tonics like iron, arsenic, and quinine are often 
indicated, and may be combined with such antispasmodics as 
valerian, asafoetida, or sumbul. The systematic passage of a 
bougie may be of great value. A mild electrical current may 
be applied through the bougie. 

ORGANIC (ESOPHAGEAL OBSTRUCTION. 

Etiology. — (1) An external tumor pressing on the oesoph- 
agus. This is most commonly an aneurism. (2) A tumor 
growing from the oesophageal wall ; generally a cancer. (3) 
A cicatrix, from ulceration. The ulcer may be due to syph- 
ilis or to some corrosive poison, as a strong acid or alkali. 
(4) A foreign body. 

Symptoms. — A slowly increasing difficulty in deglutition, 
with the regurgitation of food. The oesophagus is often much 
dilated above the constriction, and the food may collect in the 
pouch thus formed, so that regurgitation may be delayed for 
several hours. The passage of a bougie meets with a perma- 
nent obstruction. There is much loss of flesh. 

Diagnosis. — The history of syphilis or corrosive poisoning 
will suggest a cicatrix. Aneurismal obstruction can usually 



ACUTE GASTRITIS. 33 

be detected by physical examination. Aneurism should be 
excluded before a bougie is passed. The age, cachexia, pain, 
and involvement of other organs will indicate cancer. 

Prognosis. — Depends on the cause. It is unfavorable in 
aneurism and cancer. In cicatricial contraction the obstruc- 
tion may be overcome for an indefinite period. 

Treatment. — Aneurism : Prolonged rest, restricted diet, 
and potassium iodide. Cicatricial contraction: Systematic dil- 
atation with graduated bougies. Cancer : In the early stage, 
the cautious use of a bougie is advisable. In advanced cases 
the patient may be fed through a tube, and when this is no 
longer possible, life may be prolonged for a short time by 
rectal alimentation or by feeding through a gastric fistula. 

ACUTE GASTRITIS. 

(Acute Gastric Catarrh.) 

Etiology. — (1) Ingestion of indigestible food, especially 
when followed by exposure to cold and wet. (2) Toxic sub- 
stances in excess, as alcohol, strong acids, and alkalies. (3) It 
is an associated condition in certain infectious diseases, as yel- 
low fever, measles, and scarlet fever. 

Pathology. — The mucous membrane is red, swollen, and 
covered with thick mucus. It is sometimes the seat of ecchy- 
moses. 

Symptoms. — The symptoms vary much in degree. In se- 
vere cases there may be moderate fever (102°-103°) and its asso- 
ciated phenomena, with anorexia, coated tongue, intense pain 
in the epigastrium, which is tender to the touch, persistent 
vomiting, thirst, and considerable prostration. Jaundice may 
follow from the extension of the catarrh to the bile-ducts, and 
diarrhcea from its extension to the intestines. 

I Diagnosis. — It may resemble the onset of scarlet fever, but 
the history of contagion, the " strawberry tongue," sore throat, 
very rapid pulse, and eruption, characterize the latter. 
Prognosis. — Usually favorable ; it rarely lasts more than a 
few days. 
Treatment. — Absolute rest. If the stomach has not been 
completely emptied, an emetic such as ipecac may be employed. 
8 



34 DISEASES OF THE DIGESTIVE SYSTEM. 

Locally, a mustard plaster or a turpentine stupe will aid in 
relieving the distress. In severe cases no food should be 
given by the mouth until the stomach becomes retentive. 
Thirst should be allayed with cracked ice. Later, milk with 
lime-water (a teaspoonful of each) may be given hourly, and 
this may be followed by light broths in similar quantities. 

Persistent vomiting may be relieved by small doses of calo- 
mel (gr. y 1 ^), bismuth (gr. v.-x.), carbolic acid (gtt. J-J), or 
wine of ipecac (gtt. 1). 



Ft. 
Sig. 


in chart. Xo 
—One every 


Hydrarg. 
Bismuth. 
. xij. 
hour. 


chlor. mitis. 
subnit., 3j.- 


-M. 


Or 

Ft. 

Sig. 


> 

in chart. Xo 
— One every 


Creasoti, 
Bismuth. 
. xij. 
hour. 


gtt. iij.; 

subnit., 


3j-- 


-M. 


Or 


? 


^ 


Yin. ipecac, 
Tinct. nucis vom. 


, aa 


%]•- 



M. (Pepper.) 

Sig. — Two drops in water every two hours. 

Severe pain and obstinate vomiting will often yield to opium, 
in the form of suppositories. Thus : — 

fy Pulv. opii, gr. vj ; 

01. theobrom., q. s. — M. 
Ft. in suppos. Xo. vj. 
Sig.— One every three hours. 

Toxic gastritis will require in addition appropriate anti- 
dotes. 



DYSPEPSIA. 

Definition. — The word dyspepsia means ill digestion, and 
is applied to a group of symptoms which accompanies every 
disease of the stomach ; when, however, the symptoms depend 
on nothing more than simple atony, hypersensitiveness, or 
chronic catarrh, the patient is said to have dyspepsia. 

Corresponding to these conditions, three varieties have 






DYSPEPSIA. 35 

been recognized, viz. : (1) Atonic. (2) Nervous, and (3) 
Catarrhal dyspepsia. 

Etiology. — (1) Heredity. (2) All visceral diseases, as 
heart, liver, and kidney disease. (2) Overwork, mental or 
physical. (4) Gastric irritants, as tea, coffee, and alcohol in 
excess. (5) Dietetic errors, which include — insufficient mas- 
tication from bad teeth or hurried eating, too much food, in- 
sufficient food, coarse or improperly cooked food, excessive 
dilution of food with liquids, excess of condiments, and irreg- 
ular eating. 

Symptoms of Dyspepsia. — Coated tongue, perverted ap- 
petite, fulness and distress after eating, eructations, flatulence, 
" heart-burn," palpitation, headache, vertigo, disturbed sleep, 
and lassitude. 



ATONIC DYSPEPSIA. 

Characteristic Symptoms. — The tongue is pale, coated, 
flabby, and tooth-marked ; the appetite is lost ; there is a sense 
of fulness and distress over the stomach, some time after eating, 
without actual pain or tenderness. The bowels are constipated. 
There is much flatulence. The patient is pale, the muscles 
are soft, the pulse is weak, and there is great lassitude. 

Prognosis. — G ood . 

Treatment. — The diet must be carefully regulated, and 
rich and heavy food rigidly interdicted. The hygienic sur- 
roundings must be so modified that the general condition of 
the patient will be improved. s Tonics like iron, quinine, and 
strychnine are often indicated. Dilute mineral acids with 
pepsin will be required to assist the digestive process. 

Purgatives should be avoided, and constipation relieved by 
diet, mineral waters, enemas, or suppositories. 

NERVOUS DYSPEPSIA. 

This type usually occurs in those of a distinctly nervous 
temperament, and excessive mental strain and dietetic errors 
are potent etiological factors. 



36 DISEASES OF THE DIGESTIVE SYSTEM. 

Characteristic Symptoms. — The tongue is often clean. 
The appetite is very irregular — at one time it is lost ; at an- 
other it is inordinate; at another it is perverted, the patient 
craving an unnatural diet. Severe pain is a prominent symp- 
tom which is apt to appear when the stomach is empty, and 
to be relieved by eating. The term gastralgia is applied to 
this pain. Vomiting is not common, but it may occur when 
the stomach is full or empty. The gastric acidity may be 
normal or subnormal, but it is often excessive. 

Other nervous phenomena are commonly present, such as 
headache, vertigo, disturbed sleep, hypochondriasis, neuralgia, 
palpitation, and perverted sensations. 

Diagnosis. — The history, associated nervous phenomena, 
the time that the pain appears, the periods of complete relief, 
the absence of hemorrhage, cachexia, tumor, and local tender- 
ness, are the chief diagnostic points. 

Prognosis. — Good, when the cause can be removed and 
the patient thoroughly controlled. 

Treatment. — The avoidance of excitement and excessive 
mental work must be enjoined. An extended voyage may 
effect a cure. In brain-workers the value of regular physical 
exercise and frequent bathing, followed by friction of the skin, 
cannot be overestimated. On the other hand, the anemic and 
exhausted may require the "rest-cure." The patient's experi- 
ence will assist in the regulation of the diet. Tonics like iron, 
arsenic, quinine, and strychnine are often indicated. Elec- 
tricity applied to the stomach has given good results. Pepsin 
and mineral acids will be of service only in those cases in 
which examination reveals a lack of acid in the gastric juice. 
In such cases Dr. Pepper recommends : — 

I£ Quimnee sulph., gr. xxxij ; 
Strychninse sulph., gr. ss ; 
Acid, hydrochlor. dil.. f%ij. 
vel. Acid, phosphor, dil., f^iij : 
Tr. cardamom, comp., f^ij : 
Aquae, q. s. ad £§iv. — M. Filter. 
Sig. — Tablespoouful after meals. 



CATARRHAL DYSPEPSIA. 37 

CATARRHAL DYSPEPSIA. 

(Chronic Gastritis, Chronic Gastric Catarrh.) 

Catarrh of the stomach is often a primary condition result- 
ing from the ordinary causes of dyspepsia, but its frequent 
dependence on disturbed circulation from heart, lung, and liver 
disease should never be forgotten. 

Pathology. — In the early stages the mucous membrane 
is ashy-gray in color and covered with tenacious mucus. 
Ecchymoses are often noted. Microscopic examination re- 
veals degeneration of the glandular epithelium and an over- 
growth of the connective tissue. In advanced cases the walls 
may be thin from extreme atrophy of the glandular structure, 
but more often they are thick, wrinkled, and indurated from 
excessive overgrowth of connective tissue. 

Characteristic Symptoms. — The tongue is irregularly 
coated, the tip often red, and the papillae enlarged. The ap- 
petite is variable. After eating there is weight and distress, 
and often diffuse tenderness on palpation. There are fre- 
quent eructations of wind and sour liquid. 

Nausea and vomiting are frequently present; the latter may 
occur in the morning on rising, and the ejected material be 
composed of the frothy mucus which has collected in the 
stomach during the night, or it may occur some time after 
eating, and be composed of partially-digested food mixed with 
acids of fermentation, such as lactic, butyric, and acetic acids. 
The normal acid, hydrochloric, is invariably diminished or 
absent. The bowels are constipated, and the urine is scanty 
and throws down a heavy deposit of urates or phosphates. 
The nervous phenomena common to all forms of dyspepsia are 
present. 

Protracted cases, with atrophy of the gastric tubules, present 
the symptoms of pernicious anaemia. 

Diagnosis. Cancer. — After forty, haematemesis, cachexia, 
tumor, the short duration, and the involvement of other organs. 

Ulcer. — Haematemesis, sharp pain increased by eating, vomit- 
ing soon after eating, local tenderness, abundance of hydro- 
chloric acid. 



38 DISEASES OF THE DIGESTIVE SYSTEM. 

Care must be taken to determine whether the catarrh is 
primary or secondary to visceral disease. 

Prognosis. — When not dependent on organic disease of 
other viscera, the prognosis is good. 

Treatment. — Good hygienic conditions. A regulated 
diet ; in severe cases an absolute skimmed-milk diet, or par- 
tially-digested foods. Thick mucus and undigested food may 
be removed by the stomach-tube when its introduction is well 
borne. Pure or slightly alkaline water may be /employed ; 
but when there is much fermentation, one per cent, of salicylic 
acid may be added with advantage. Irrigation should be 
practised daily, or every other day, preferably before break- 
fast, and the tube should be kept in position until the escap- 
ing fluid is quite clear. 

"When lavage is not well borne, the patient may be directed 
to sip before breakfast a half pint of some hot alkaline water, 
such as Carlsbad. This is especially indicated when there is 
constipation. 

Artificial Carlsbad salt : — 

I£ Sodii sulph., §v ; 
Sodii bicarb., gij ; 
Sodii chlorid., %).— M. (Welch.) 
Sig. — 3j in a half pint of water half hour before breakfast. 

Dilute hydrochloric acid is nearly always indicated, and it 
may be combined advantageously with pepsin. 

fy Tinct. nucis vom., f.^ss ; 
Acid, hydrochlor. dil., f^ij ; 
Pepsin, sacchar., fgiij ; 
Aqua?, q. s. ad. f^iv.— M. 
Sig. — A teaspoonful after meals. 

The catarrhal process is often favorably influenced by sub- 
nitrate of bismuth, or nitrate of silver. When there is much 
fermentation and flatulence, salicylate of bismuth (gr. v-x), 
or subnitrate of bismuth with some antiferment may be 
employed. 

fy Salol, gr. xl ; 

Bismuth, subnitrat., Jss. — M. 
Ft. in chart. Xo. xx. 
Sig. — One powder half an hour before meals. 



GASTRALGIA. 39 

Instead of salol, creasote (gtt J) may be added to each powder. 
Constipation should be relieved by diet, mineral waters, 
enemas, suppositories of glycerin or gluten, or by mild laxa- 
tives. Acid eructations and " heart-burn" may be relieved by 
digestants and dilute acids, taken immediately after meals ; or 
by alkalies, with or without such antiferments as creasote, 
salol, or naphthol, taken one or two hours after meals. 

GASTRALGIA. 

(Gastrodynia, Neuralgia of the Stomach.) 

Definition. — A painful paroxysmal affection of the 
stomach, unassociated with any organic lesion. 

Etiology. — Nervous temperament, overwork, anaemia, and 
dietetic errors are the predisposing causes. 

Symptoms. — Paroxysms of severe pain in the epigastrium, 
usually radiating to the back, occurring when the stomach is 
empty, and relieved by pressure and the ingestion of food or 
warm stimulating drinks. 

Diagnosis. Gastric Ulcer. — In this disease the pain is more 
continuous, is made worse by eating, and is often associated 
with local tenderness and hsematemesis. 

Cancer. — The age, history, continuous pain which is in- 
creased by eating, hsematemesis, tumor, cachexia, anorexia, 
and absence of hydrochloric acid will separate cancer from 
gastralgia. 

Angina Pectoris. — The radiation of the pain from the heart 
down the arm, fixation of the body, fear of impending death, 
and the associated symptoms of fatty heart, such as arcus 
senilis, rigid radials, and altered heart-sounds, will separate 
angina pectoris from gastralgia. 

The lancinating pains of locomotor ataxia sometimes attack 
the stomach and produce what are termed gastric crises. 
These can be distinguished from simple gastralgia by the 
absence of the patellar reflex, by the Argyle-Robertson pupil, 
the loss of coordination, and by paroxysmal pains in other 
parts of the body. 

Prognosis. — Favorable, but duration indefinite. 



40 DISEASES OF THE DIGESTIVE SYSTEM. 

Treatment. Attach. — Hot fomentations should be ap- 
plied locally, and Hoffmann's anodyne (3 g s), chloroform (gtt. 
x), dilute hydrocyanic acid (gtt. ij in hot water), or the follow- 
ing mixture may be given internally : — 

]£ Spt. viu. gal. 

Tinct. opii camph., aa 13 ss ; 
01. caryoph., gtt. x. — M. 
Sig. — A teaspoonful in hot water. 

In severe cases morphia will be required. 
The Interval. — Correct the hygiene, regulate the diet, and 
enjoin rest. Travel may be extremely valuable. Neuras- 
thenia may require the " rest-cure." Tonics are often indi- 
cated. "When there is hyperacidity, salicylate of bismuth, 
carbonate of soda, or aromatic spirits of ammonia, after meals, 
may be very serviceable. Arsenic, valerian, and dilute hydro- 
cyanic acid are remedies of great value. 
« 

]£ Sodii arseniat., gr. ss ; 

Ext. cannabis ind.,gr. iij. — M. (DaCosta.) 
Ft. in pil. No. xx. 
Sig. — One, three times daily. 

GASTRIC ULCER. 

(Simple Ulcer, Perforating Ulcer.) 

Definition. — An ulcer arising without obvious exciting 
cause, but which is probably due to the digestive action of 
highly acid gastric juice on a part of the stomach whose nutri- 
tion has been impaired by some local disturbance of the cir- 
culation. 

Etiology. — Female sex, age (between the fifteenth and the 
fortieth year), overwork with poor food, and anaemia are the 
predisposing causes. 

Pathology. — From some local disturbance of the circula- 
tion — injury, hemorrhage, thrombosis, embolism, or spasm of 
the vessels — the part is self-digested. 

The ulcer is round or oval, usually situated at the pylorus, 
on the posterior wall, near the lesser curvature. It has a 
punched-out appearance, is conical in shape, with the apex 
towards the peritoneum, and is without an inflammatory areola. 



GASTRIC ULCER. 41 

The floor of the ulcer is usually smooth, and may be formed 
by any one of the coats of the stomach. A series of ulcers is 
not uncommon, so that more than one may be detected. 

Symptoms. — The general symptoms of dyspepsia ; loss of 
flesh and strength ; and the following characteristic symp- 
toms : (1) Severe pain, increased by eating ; it may radiate to 
the back ; it may be paroxysmal ; it may be worse in certain 
positions. (2) Local tenderness. (3) Persistent vomiting after 
taking food ; the gastric juice is unnaturally acid. (4) Hemor- 
rhage is common ; it varies in amount from a trace of blood 
to a quart or more. 

In some cases only the symptoms of dyspepsia are present, 
while in others all symptoms may be absent, and in the latter 
hemorrhage or perforation may be the first indication. 

Events. — (1) Resolution. (2) Death from exhaustion, 
hemorrhage, perforation and peritonitis, or pyloric obstruction 
from cicatricial contraction. 

Diagnosis. Cancer. — The age (after forty), history, down- 
ward course, short duration, extreme cachexia, often out of 
proportion to gastric symptoms, tumor, absence of hydro- 
chloric acid and blood less in amount and more disintegrated. 

Gastralgia. — The pain usually appears when the stomach is 
empty, and is relieved by food and pressure ; no hemorrhage, 
no local tenderness ; other nervous phenomena are commonly 
present. 

Chronic Gastritis. — Hemorrhage rare, tenderness diffuse, 
pain less marked, vomiting less frequent and persistent, gastric 
acidity less than normal. 

Prognosis. — Guardedly favorable ; such complications as 
hemorrhage or perforation may occur without warning, and 
relapses from new ulcers are not uncommon. 

Treatment. — Absolute rest in bed and rectal feeding. 

Later, and in less severe cases from the beginning, pre- 
digested milk, milk and lime-water, buttermilk, broths, soft- 
boiled eggs and preparations of corn-starch may be given by 
the mouth at regular and frequent intervals. This restricted 
diet should be continued for eight or ten weeks, and the return 
to solid food should be quite gradual. The more complete the 
rest the more rapid will be the cure. Lavage is contraindi- 



42 DISEASES OF THE DIGESTIVE SYSTEM. 

cated, but the stomach may be cleaned by the sipping of hot 
alkaline water in the morning before breakfast. Internally, 
subnitrate of bismuth and nitrate of silver are useful remedies. 

$. Argenti nitratis, gr. v ; 
Ext. opii, gr. iij. — M. 
Ft. in pil. iSTo. xx. 
Sig. — One pill thrice daily half an hour before meals. 

Or, 

J$l Bismuth, subnitrat., ^vj-^j ; 

Creasot., gtt. x ; 

Morphin. sulph., gr. i-ij. — M. 
Ft. in chart. No. xx. 
Sig. — One powder before meals. 

Instead of morphia cocaine (gr. J) may be added to each 
powder. 

When there is much pain counter-irritation will be of ser- 
vice. Hemorrhage will require absolute rest ; morphia (gr. J) 
and fluid extract of ergot hypodermically ; an ice-bag to the 
stomach, and pellets of ice and tannic acid (gr. v-x) by the 
mouth. 

GASTRIC CANCER. 

Varieties. — (1) Hard cancer (scirrhus). (2) Soft cancer 
(medullary or encephaloid). (3) Epithelioma. (4) Colloid 
cancer. 

Etiology. — Male sex, age (after forty), heredity, and ulcer- 
ation of the stomach are predisposing causes. 

Pathology. — Cancer of the stomach is usually primary ; 
other organs being involved secondarily. The scirrhous form 
is the most common. As the pylorus is the usual seat, gastric 
dilatation is a natural sequence. 

Symptoms. — The general symptoms of dyspepsia, with the 
following characteristic symptoms : Continued pain, often 
tenderness ; vomiting of partially-digested food ; absence of 
free hydrochloric acid in the gastric juice (confirmatory only) ; 
hsematemesis, the loss being usually slight, and the blood so 
altered by the gastric juice that it presents a " coffee-ground" 
appearance ; presence of a tumor ; loss of flesh and strength ; ex- 
treme anaemia; involvement of the superficial lymph glands. 



DILATATION OF STOMACH. 43 

When the pylorus is involved, symptoms of gastric dila- 
tation will be added. These are : Vomiting, after the lapse 
of several hours or days, of large quantities of fermented ma- 
terial rich in sarcinae ventriculi, increased area of gastric tym- 
pany on percussion, and a reversed peristaltic wave on inspec- 
tion. 

Diagnosis. — The differential diagnosis of gastric cancer 
from ulcer, gastralgia, and chronic gastritis has already been 
discussed. 

Prognosis. — Absolutely fatal. The duration is from six 
months to two years. 

Treatment. Palliative. — A liquid or semi-liquid diet. 
Rest. Hydrochloric acid and pepsin are often required to as- 
sist digestion. When the stomach is dilated lavage may give 
relief. Pain should be relieved by morphia. The other 
symptoms will require the treatment indicated in gastric ca- 
tarrh. At present, operative interference could scarcely be 
recommended. 

PYLORIC OBSTRUCTION AND DILATATION 
OF THE STOMACH. 

Etiology. — The causes of pyloric obstruction: (1) Pyloric 
tumors, usually malignant. (2) Tumors of adjacent viscera 
pressing on the pylorus or duodenum. (3) Cicatrix of an 
ulcer. (4) Fibroid thickening from chronic catarrh. 

Pyloric obstruction increases the resistance offered to the 
expulsion of food, and in its efforts to overcome this, the stom- 
ach first becomes hypertrophied and then dilated. 

Causes of Dilatation of the Stomach (Gastrectasis). — (1) Py- 
loric obstruction. (2) Relaxation of the walls from simple 
atony or catarrh. (3) Excessive ingestion of food or drink. 

Symptoms. — The general symptoms of dyspepsia, with the 
following characteristic symptoms, most of which relate to the 
vomit : Vomiting occurs long after eating, sometimes sev- 
eral hours or days; the amount is often excessive, sometimes 
several quarts; it is sour and fermented, and on standing sep- 
arates into a sediment of undigested food and a supernatant 



44 



DISEASES OF THE DIGESTIVE SYSTEM. 



liquid, which is turbid and frothy ; the ejected material is rich 
in torulse and sarcinse ventriculi. There is obstinate constipa- 
tion. 

Fig. l. 



<& 




a. Sarcina ventriculi. b. Torula eerevisiae. 



Physical Signs. Inspection. — Bulging over the epigas- 
trium ; in thin subjects the outline of the stomach may be 
visible. Sometimes a peristaltic wave is detected. 

Palpation. — A splashing fremitus. 

Percussion. — Increased area of gastric tympany. Artificial 
distention of the stomach with carbonic-acid gas, evolved by 
the administration of bicarbonate of soda and tartaric acid, is 
rarely necessary, and is sometimes harmful. 

Auscultation. — Splashing sounds. These are often audible 
at some distance, and hence are a frequent source of annoy- 
ance to the patient. 

Mensuration. — Normally an oesophageal sound may be in- 
serted a distance of 60 c.c. from the teeth, in dilatation it may 
be inserted 65 or 70 c.c. 

Prognosis. — Depends on the cause ; it should always be 
guarded. It is more favorable in dilatation without obstruc- 
tion. In cicatricial contraction operative interference has given 
fair results. In cancer the prognosis is absolutely unfavor- 
able. 

Treatment. — The diet should be light and nutritious, not 
bulky, and should be given in small amounts at frequent in- 
tervals. Lavage practised two or three times weekly is of 
o-reat value. In cancer the treatment is palliative. In fibroid 



CONSTIPATION. 45 

thickening and cicatricial constriction, dilatation of the pylorus 
(Loreta's operation) or the establishment of a gastro-duodenal 
fistula may be suggested. These operations have been fairly 
successful. In simple dilatation, treat the catarrh and apply 
massage and electricity ; the latter may be applied to the in- 
terior of the stomach by means of a bipolar stomachal elec- 
trode. (Rockwell.) Tonics, especially strychnia, are often 
valuable adjuncts. An abdominal support often relieves some 
of the distressing symptoms. 

H^EMATEMESIS. 

(Gastrorrhagia. ) 

Etiology. — (1) Traumatism. (2) Acute gastritis. (3) 
Obstruction to the circulation, as in chronic heart, lung, and 
liver disease. (4) Vicarious menstruation. (5) Blood dys- 
crasia, as in scurvy, infectious fevers, grave anaemia, purpura, 
etc. (6) Rupture of an aneurism. (7) Gastric ulcer. (8) 
Gastric cancer. (9) Swallowing of blood from nose, mouth, 
or throat. (10) Hysteria. 

Diagnosis. Hcematemesis. — Blood is often clotted and 
mixed with food, is acid in reaction; the subsequent stools 
may be tarry, and the associated symptoms usually point to 
the stomach or adjacent organs. 

Hcemoptysis. — Blood is red, frothy, and alkaline in reaction, 
the subsequent expectorations are streaked with blood, and 
physical signs usually indicate the cause. 

Treatment. — Absolute rest ; abstinence from food by the 
mouth : an ice-bag to the stomach. Pellets of ice may be 
sucked. Tannic acid (gr. v-x) by the mouth, and fluid ex- 
tract of ergot (3 SS ) with morphia (gr. J) hypodermically. If 
the hemorrhage has been profuse, use subcutaneous injections 
of weak saline solutions ; give iron by the mouth, and advise 
the use of salty broths. 

CONSTIPATION. 

Definition. — An unnatural detention of fecal matter. 
Etiology. — (1) Many acute and chronic diseases which 
lessen peristalsis and secretion, as most chronic visceral dis- 



46 DISEASES OF THE DIGESTIVE SYSTEM. 

eases, all nervous diseases, anaemia, and the infectious fevers, 
except typhoid. (2) Sedentary habits. (3) Concentrated 
food. (4) Certain drugs, as lead and opium ; it is an after- 
effect of strong purgatives. (5) Atony of the intestinal Avail, 
common in the old and debilitated. (6) Stricture. 

Symptoms. — Infrequent stools, dyspepsia, fetid breath, 
headache, vertigo, lassitude, anaemia. 

Results. — In aggravated cases : dyspepsia, diarrhoea from 
irritation, fecal accumulation, hemorrhoids, fissure, fistula, 
prolapse of the rectum. 

Tkbatmekt. — A regular time for defecation should be ob- 
served. Systematic exercise, abdominal massage, and elec- 
tricity are valuable aids. Encourage the use of water, bran- 
bread, green vegetables, and stewed fruits. In mild cases a 
glass of water or an orange before breakfast will suffice. Ene- 
mata of water, or glycerine 3j~3iv), or suppositories of glyc- 
erine or of gluten may be required. 

Mineral waters, like Friedrichshall or Hunyadi, often give 
relief. 

In obstinate cases mild laxatives must be employed ; cascara 
sagrada is one of the best. The dose of the extract is one to 
three grains ; of the fluid extract, half to a fluid drachm. 

Sometimes combinations are desirable. 

I£ Aloin, gr. iv ; 

Styrclminee, gr. ^ ; 

Ext. belladonna?. 

Pulv. ipecac, aa gr.ij.— M. 
Ft. in pil. Xo. xx. 
Sig. — One or two as required. 

Or, 

fy Pulv. rhei, gr. xl ; 

Pulv. aloes, gr. xx ; 

Ext. physostig., gr. iij ; 

Ol. caryophylli, gtt. iij. — M 
Ft. in pil. Xo. xx. 
Sig. — One or two as required. 



DIARRHCEA. 47 

INTESTINAL COLIC. 

(Enteralgia, Tormina.) 

Definition. — A painful spasmodic affection of the intes- 
tines. 

Etiology. — It usually results from irritating food, flatu- 
lence, or fecal accumulation. It is sometimes rheumatic. It 
may be reflex from ovarian or uterine disease. It is also a 
symptom of lead-poisoning, intestinal inflammation, and intes- 
tinal obstruction. 

Symptoms. — Paroxysms of severe pain of a twisting char- 
acter, centering around the umbilicus, and relieved by pressure. 
The abdomen is usually distended. Severe attacks may lead 
to incipient collapse, indicated by cold sweats, pinched features, 
feeble pulse, and vomiting. The attack lasts from a few 
minutes to several hours, and usually ends by a discharge of 
flatus. 

Diagnosis. Lead Colic. — History, blue line on the gums, 
retracted abdominal walls, and lead in the urine. 

Biliary Colic. — Pain radiating from the liver to the back 
and right shoulder, jaundice, and calculus in the stool. 

Renal Colic. — Pain radiating down the ureter to penis and 
testicle, blood, mucus, pus, or calculi, in the urine. 

Abdominal Aneurism. — Tumor, pulsation, bruit 

Progn osis. — Favorable. 

Treatment. — Apply hot applications to abdomen, and 
administer morph. (gr. J) with sulphate of atropine (gr. t^-q) 
hypodermically. Subsequently employ a saline or mercurial 
purge. 

Lead Colic. — Use sulphate of magnesium as a cathartic, and 
iodide of potassium (gr. v-x, thrice daily) to eliminate the 
lead. 

DIARRHOEA. 

Oefinition. — A condition in which the stools are too fre- 
quent or too liquid. Like dyspepsia, it is a symptom of many 
pathological conditions. 

Etiology. — (1) It results from inflammation of the in- 



48 DISEASES OF THE DIGESTIVE SYSTEM. 

testines, as enteritis, enterocolitis, dysentery. (Inflammatory 
diarrhoea.) (2) It is a symptom of certain infections diseases, 
as typhoid fever, cholera. (Symptomatic diarrhoea.) (3) It is 
produced by certain drugs, as laxatives and purgatives. (4) It 
may be an expression of cachexia occurring as a final symptom 
in cancer, diabetes, and chronic Bright's disease. (Colliqua- 
tive diarrhoea.) (5) It may be a closing symptom in acute 
febrile diseases which end by crisis, as typhus fever, re- 
mittent fever. (Critical diarrhoea.) 6. It may result from 
nervous excitement or sensational disturbance. This is prob- 
ably due to a vaso-motor paresis of the intestinal vessels (an 
intestinal " blush"), and the subsequent outpouring of serum. 
(Nervous diarrhoea.) 

INTESTINAL CATARRH. 

(Diarrhoea, Catarrhal Enteritis.) 

Etiology. — Warm weather, childhood, and bad hygiene 
are general predisposing causes. It is usually excited by a 
sudden change in temperature, or by irritating products in the 
intestinal canal, as harsh food, ptomaines, or bacteria. It may 
be induced by corrosive poisons, as antimony, arsenic, mer- 
cury. 

Pathology. — The mucous membrane, especially of the 
upper bowel, is injected, swollen, and covered with tenacious 
mucus. The solitary and agminated glands are enlarged, and 
are, sometimes the seat of pinhead ulcerations. 

In chronic enteritis the mucous membrane is often thickened 
from an overgrowth of connective tissue, but in some instances 
it is unusually thin from atrophy of the coats and destruction 
of the glands. 

Symptoms. Acute Enteritis. — Frequent stools, three to 
twelve or more a day ; they are usually of a yellowish or 
greenish color, and frequently contain undigested food. 
Colicky pains, and rumbling noises (borborygmi), coated 
tongue, anorexia, and sometimes slight fever. 

Chronic Enteritis. — Frequent liquid stools which vary in 
color and character according to the seat of catarrh ; much 



INTESTINAL CATARRH. 49 

undigested food (lientery) indicates involvement of the upper 
bowel ; and much mucus, involvement of the lower bowel. 
The excessive drain leads to anaemia, emaciation, and weak- 
ness. 

Membranous Enteritis. — This term has been applied to two 
conditions : (1) A true croupous enteritis, which is associated 
with the formation of a false membrane, and which is seeu in 
cachectic states, in acute infectious diseases, and as a result of 
mineral poisoning. (2) Mucous colic, or mucous colitis, a 
chronic form of colitis, usually occurring in women of a 
marked nervous temperament, and characterized by paroxysms 
of severe pain, and the discharge of gray translucent casts 
which, however, are not membranous, but mucoid in character. 

Diagnosis. Dysentery. — Bloody and mucous discharges, 
tenesmus, greater prostration. 

Entero- colitis. — Moderate fever, greater prostration, tender- 
ness along the colon ; stools contain mucus, blood, and ma- 
terial resembling chopped spinach. 

Prognosis. — Good, under favorable conditions. 

Treatment. — In adults. — Rest. Liquid diet. When 
there is retention of irritating material, indicated by the his- 
tory, sharp pain, abdominal distention, and small stools, ad- 
minister a laxative, as calomel, or castor oil with laudanum. 

]£. Hydrarg. chlor. mit., gr. ij ; 
Sodii bicarb., gj.— M. 
Ft. in chart. No. xii. 
Sig. — One every hour until five or six have been taken. 

Or— 

Y$l 01. ricini, 

Syr. rliei aromat., aa f.^ss ; 

Tinct. opii, gtt. x-xx. — M. 
Repeat, if necessary. 

When the bowel has been thoroughly emptied, opium, as- 
tringents, and intestinal antiseptics will be required. Thus : — 

J$l ^Bismuth, subnit., 5ss ; 
Morphin. sulph., gr. j ; 
Creasoti, gtt. vj. — M. 
Ft. in chart. No. xii. 
Sig. — One every two hours. 
4 



50 DISEASES OF THE DIGESTIVE SYSTEM. 

Or— 

1^. Bismuth, subnit., 
Cretse prsepar. , aa £ij ; 
Tinct. opii camph., f^iss ; 
Tinct. kino, f^ij ; 
Pulv. acacise, q.s ; 

Aquae cinnamomi, q.s. ad. f^vj. — M. 
Sig. — A tablespoonful every three hours. 

Chronic Diarrhoea. — Liquid diet. Rest. Intestinal antisep- 
tics (salicylate of bismuth, naphthalin, salol), and opium with 
mineral astringents. 

DiarrhcEa in Children. — Absolute cleanliness. Frequent 
bathing. A change of air, if possible. If the child is bottle- 
fed, the milk must be sterilized and given at regular intervals. 

If the diarrhoea still persists, milk should be abandoned, and 
the child fed for a few days on egg albumin, beef juice, or 
beef peptonoids. A flannel binder should be applied to the 
abdomen. The bowels should be emptied with castor oil (3j) 
to which may be added a few drops of paregoric ; or — 

I£ Hydrarg. chlor. mit. , gr. j ; 

Bismuth, salicylat., gr. xxxvj ; 

Pulv. zingiber., gr. xij. — M. 
Ft. in chart. No. xii. 
Sig. — One every hour. 

After this has operated, astringents may be employed. 

fy Sodii salicylat., gr. xij ; 

Bismuth, subnit., gr. xxxvi ; 
Pulv. aromat., gr. vj, — M. 
Ft. in chart. No. xii. 
Sig. — One every two hours. 

$: Sodii bicarb., £ss ; 
Syr. rhei aromat., ^ss ; 
Aq. menth. pip., gijss.— M. (Starr.) 
Sig. — 3j every two hours. 

Or— 

I£ Bismuth, subnit., gr. j-iij ; 
Tinct. opii camph., g'tt. iv ; 
Mist, cretse. 

Aquae anisi, aa gss. — M. (Hatfield.) 
Sig.— Every two hours. 



ENTERO-COLITIS. 51 

ENTERO-COLITIS. 

(Follicular Enteritis.) 

Definition. — An inflammation involving mainly the 
ileum and colon, and affecting especially the lymphatic glands. 

Etiology. — Warm weather, childhood, improper food, and 
bad hygiene are predisposing factors. 

It usually follows catarrhal enteritis or cholera infantum. 

Pathology. — The mucous membrane is red, swollen, and 
oedematous. The solitary and agminated glands are swollen 
and often ulcerated. 

Symptoms. — Frequent stools, at first yellow, later green, 
and mixed with curd, mucus, blood, and sometimes material 
resembling chopped spinach. The dejecta are neutral or acid 
in reaction. There is moderate fever (101 °-l 02°), with its 
usual phenomena. The abdomen is distended, and tender 
along the colon. Vomiting is usually present. The child 
grows pale, wastes, and assumes a senile appearance. Death 
may be preceded by coma and convulsions. (Spurious hydro- 
cephalus.) 

Diagnosis. — Reference has already been made to its sepa- 
ration from catarrhal enteritis. 

Cholera infantum : Abrupt onset, very high fever, persist- 
ent serous vomiting and purging, and early collapse. 

Prognosis. — Grave, yet recoveries follow under favorable 
conditions. 

Treatment. — Much the same as in catarrhal enteritis. 
Stimulants are frequently required. Weak stupes or spice 
poultices should be applied to the abdomen. Topical treat- 
ment should not be neglected. The bowel should be irrigated 
once a day with a pint or more of tepid water containing one 
per cent, of benzoate of soda or salicylic acid. The irrigation 
may be followed by the injection of an ounce of water con- 
taining nitrate of silver (gr.J-1). 



52 DISEASES OF THE DIGESTIVE SYSTEM. 

DYSENTERY. 

(Bloody Flux. ) 

Definition. — An inflammatory disease of the colon, char- 
acterized by tenesmus, and the passage of small, mucous, and 
blood-streaked stools. 

Etiology. — (1) Warm climates and warm weather; (2) 
bad hygience ; (3) ingestion of irritating food * (4) exposure 
to cold and wet ; (5) cachectic states (scurvy, gangrenous 
stomatitis, and Bright's disease) are predisposing factors, and 
alone may produce simple dysentery ; but the tropical form 
(also occurs in cold climates) seems to be excited by a vegeta- 
ble parasite, the amoeba coli. 

The disease frequently occurs in epidemic form. 

Varieties. — (1) Acute catarrhal or sporadic dysentery. 
(2) Amoebic or tropical dysentery. (3) Malignant or diph- 
theritic dysentery. (4) Chronic dysentery. 

Pathology. Catarrhal Dysentery. — Mucous membrane of 
the colon is red, swollen, oedematous, and in some cases ulcer- 
ated. 

Fig. 2. 




Amoeba coli. 

Amoebic Dysentery. — The mucous membrane is swollen from 
oedema and cellular infiltration. The latter causes superficial 
necrosis, and the formation of irregular ulcers which more or 
less undermine the surrounding mucosa. The amoebae are 
found in the floor of the ulcers, and in the surrounding tissue. 
In some cases, false membrane and sloughs appear. Abscess 
of the liver is a common complication. 

Diphtheritic Dysentery. — The mucous membrane is intensely 
swollen, and covered with a false membrane, w T hich results 



DYSENTERY. 53 

from coagulation-necrosis. The separation of the membrane 
is followed by ulceration and sloughing. 

Chronic Dysentery. — May be simple or amoebic. The coats 
are greatly thickened and ulcers are usually found. Cicatri- 
cial contractions sometimes follow. 

Symptoms. Acute Catarrhal Dysentery. — Moderate fever 
and its associated phenomena, prostration, colic, abdominal 
tenderness, tenesmus (fulness in the rectum with a constant 
desire to defecate) with small, mucous, and bloody stools. 

Amoebic Dysentery. — May begin as an acute or chronic dis- 
ease. The symptoms are similar to catarrhal dysentery, but 
the disease is more protracted, and often marked by intermis- 
sions and exacerbations ; the stools are more fluid and contain 
the amoeba coli, and abscess of the liver is a more frequent 
complication than in other forms of dysentery. 

Malignant or Diphtheritic Dysentery. — To the ordinary 
symptoms the following typhoid phenomena are added : Mut- 
tering delirium, stupor, subsultus, carphologia, and a brown, 
fissured tongue. The stools also contain false membrane and 
sloughs. 

Chronic Dysentery. — Great loss of flesh and strength ; ex- 
treme anaemia ; the discharges contain considerable mucus 
and at times are bloody. Tenesmus and pain may be absent. 
The history of the initial symptoms will establish the diagnosis. 

Diagnosis. Diarrhoea. — Absence of tenesmus and of 
mucoid and bloody stools. 

Intussusception. — Late development of fever, stools more 
bloody than mucoid, the presence of a " sausage-like " tumor 
and persistent vomiting. 

Prognosis. — In acute catarrhal dysentery the prognosis is 
good ; recovery usually follows in from a few days to a week. 
In amoebic dysentery the prognosis should be guardedly 
favorable; relapses are common, and abscess of the liver is 
liable to occur. The duration in favorable cases is from six 
to eight weeks. Malignant dysentery is always a grave dis- 
ease and often proves fatal. 

Complications. — Peritonitis from extension or perforation, 
hepatic abscess, stricture, and paralysis from neuritis. 

Treatment. Acute Dysentery. — Absolute rest and the (Mi- 
forced use of the bed-pan. Liquid diet. Apply externally 



54 DISEASES OF THE DIGESTIVE SYSTEM. 

hot fomentations, mustard-poultices or leeches. A mild laxa- 
tive is indicated in the beginning ; sulphate of magnesia (3ij), 
or castor-oil and laudanum might be selected, and either may 
be repeated until the effect is produced. 

Internally. — Bismuth is a valuable remedy, salicylate of 
bismuth (gr. x), or subnitrate of bismuth with salol or creasote 
may be employed. 

I£ Morphin. sulph., gr. j ; 

Bismuth, subnit., ^ij ; 

Creasoti, gtt. vj. — M. 
Ft. in pulv. No. xii. 
Sig. — One every hour or two. 

Or, 

^ Salol, 3j ; 

Bismuth, subnit., 

Sodii bicarb., aa gr. c— M. 
In twenty capsules. (Dtjjardin-Beaumetz.) 

Sig. — One three or four times daily. 

Musser recommends — 

fy_ Quininse sulph., gr. xl ; 

Ext. opii, gr. v ; 

Mass. hydrarg., gr. x. — M. 
Ft. in pil. No. xx. 
Sig. — One or two every two or three hours. 

In some cases, particularly in those associated with bilious 
symptoms, ipecacuanha, in large doses (gr. xx-xxx, repeated 
every three or four hours), is very serviceable. To prevent 
emesis, twenty drops of laudanum should be given half an hour 
before the administration of the ipecacuanha. Topical treat- 
ment should never be omitted. In mild cases opium supposi- 
tories will prove very beneficial ; in severe cases enemata of 
thin starch-water with laudanum (gtt. xx-xxx) should be 
substituted for the suppositories. H. C. Wood highly recom- 
mends the use of ice suppositories, one every two to five 
minutes for half an hour, followed by suppositories of ergot 
and iodoform : — 

fy Ext. ergot., gr. lxxij ; 

Iodoform., ^ss ; 

01. theobrom., q. s.— M. 
Ft. in suppos. No. vi. 
Sig. — One every two hours until four or five have been taken. 



CHOLERA MORBUS. 55 

Astringent injections of nitrate of silver or lead acetate should 
be reserved for subacute or chronic cases. 

Injections of warm solutions of quinine (50V0 * roVo") nave 
recently been employed in amoebic dysentery with advantage. 
(Osier.) Creolin (a drachm to the pint) has given good results 
in similar cases. 

In malignant dysentery, quinine, alcohol, and turpentine 
are indicated. 

Chronic Dysentery. — Rest ; liquid diet ; intestinal antisep- 
tics (salicylate of bismuth), and copious injections of nitrate of 
silver in aqueous solution, as recommended by Wood. Begiu 
with one or two pints (gr. xx to the pint), and inject through 
a tube pushed far up the bowel ; later, increase to three or 
four pints (gr. xxx to the pint). The injections may be em- 
ployed once or twice weekly. 

CHOLERA MORBUS. 

(English Cholera, Cholera Nostras.) 

Definition. — An acute, sporadic disease, resembling Asiatic 
cholera, but not excited by the comma bacillus of Koch. 

Etiology. — The summer season predisposes, and irritating 
food, as unripe fruit, and a sudden change of temperature are 
the usual exciting causes. A ptomaine or a special bacillus 
probably induces the disease. 

Symptoms. — Intense cramps in the stomach, vomiting and 
purging of bilious material, moderate fever, and great pros- 
tration. In severe cases the discharges become serous, and 
symptoms of collapse develop. 

Diagnosis. Asiatic Cholera. — The presence of an epidemic ; 
not bilious, but rice-water discharges ; the detection of Koch's 
comma bacillus. 

Corrosive Poisons (as antimony). — History ; the vomiting 
preceding purging ; burning pain in oesophagus and rectum; 
and bloody mucous discharges. 

Prognosis. — Favorable; death rarely occurs. Duration, 
twenty-four to forty-eight hours. 

Treatment. — Hot applications to the abdomen. Morphia 
(gr. J) with atropia (gr. fio)? hypodermicallv, repeated if 



56 DISEASES OF THE DIGESTIVE SYSTEM. 

necessary. When the pain is less severe opium may be given 
by the month or rectum. Ice is soothing and relieves the 
thirst. When vomiting is the most troublesome symptom the 
iollowing will be beneficial : — 

I£ Morph. sulph. , gr. j ; 

Creasoti, gtt. vj ; 

Bismuth, subnit., 31J. — M. 
Ft. in chart. No. xii. 
Sig. — One every hour. 

Prostration will require stimulants, like aromatic spirits of 
ammonia or brandy. 

In many cases the following mixture will be all that is 
required : — 

I£ Tinct. opii camph., f^ss ; 
Spt. amnion, aromat., fsjj ; 
Magnes. optim., 3j ; 
Aq. menth. piperita?, q. s. ad. 13 Iv. — M. 

(Hartshorne. ) 
Sig. — A teaspoonful every twenty minutes. 

CHOLERA INFANTUM. 

Definition. — An acute disease of childhood, characterized 
by high fever, vomiting, purging, and collapse, and dependent 
upon an inflammation of the gastro-intestinal traet, and some 
disturbance of the sympathetic ganglia. 

Etiology. — Hot weather, faulty feeding, dentition, and bad 
hygiene are predisposing factors. 

Pathology. — The mucous membrane of the stomach and 
intestines is red, swollen, and oedematous ; the glands are en- 
larged or ulcerated. The profuse serous discharges and rapid 
collapse must be due, in part, to some disturbance of the sym- 
pathetic nerves. 

Symptoms. — The onset may be gradual or abrupt. Diar- 
rhoea is usually the initial symptom ; the stools are thin and 
serous, have a musty odor and an alkaline reaction. Vomit- 
ing soon develops, and the gastric irritability is so great that 
everything is rejected. Thirst is intense, the temperature is 
very high (105° to 108°); the pulse is rapid and feeble; the 
urine is scanty. Collapse follows, and is indicated by the 



CHOLERA INFANTUM. 57 

pinched features, hollow eyes, sunken fontanelles, and cold 
surface. Even at this time a reaction may set in, but more 
commonly death results from exhaustion. The end may be 
characterized by the symptoms of spurious hydrocephalus — 
restlessness, convulsions, irregular pupils, and coma ; and as 
these phenomena are unassociated with any cerebral lesion 
they are probably toxeemic. 

Diagnosis. Enter •o-colitis. — Gradual onset, moderate fever, 
vomiting less marked, stools more mucous than bloody and 
neutral or acid in reaction, pulse not so rapid, and no tendency 
to sudden collapse. 

Prognosis. — Grave. Under conditions most propitious 
death may result in from one to three days; on the other 
hand, no aspect is too serious to admit of recovery. Entero- 
colitis is a common sequel. 

Treatment. — If possible, the child should be removed to 
the country or seashore. It should be kept in the open air. 
Cleanliness is essential to success, and frequent bathing with 
cool water is desirable. A spice-plaster or a weak stupe should 
be applied to the abdomen. 

The nourishment should consist of barley-water, beef-juice, 
wine-whey, chicken-broth, or frozen blocks of beef-tea ; these 
should be given in small quantities at frequent intervals. 
Pellets of ice should be given to allay thirst. A few drops of 
brandy or of aromatic spirits of ammonia may be required at 
frequent intervals to combat prostration. 

To arrest vomiting use calomel (gr. -j^), subnitrate of bismuth 
(gr. iij-v), or nitrate of silver. 

T$l Argenti nitrat., gr. ss-j ; 
Syr. acacise, 13 j ; 
Aquae, f^ij. — M. 
Sig. — A teaspoonful every two hours. 

For the diarrhoea, laudanum (gtt. ij-iij) with starch-water 
(3j) may be given every three or four hours by the rectum. 
Or the following may be given by the mouth : — 

J$l Liquor, morph. sulph., f^j ; 
Acid, sulphur, aromat., TTL xxiv ; 

Elix. curacose, f,|ss ; 
Aquse, q. s. ad. fsiij. — M. 
Sig.— One teaspoonful every two hours for a child six months old. 



58 DISEASES OF THE DIGESTIVE SYSTEM. 

When vomiting and purging seem uncontrollable, morphia 
fe r - T20 to 100) hypodermically may be very useful. 

Irrigation of the stomach and bowel with warm water has 
been highly recommended, and though heroic sometimes gives 
brilliant results. In collapse, use a hot bath to which a little 
mustard or red pepper has been added ; then place the child 
in a horizontal position, cover with warm blankets, and ad- 
minister stimulants freely. 

TYPHLITIS AKD APPENDICITIS. 

Definition. — Inflammatory affections of the right iliac 
fossa have been divided into : (1) Typhlitis, an inflammation 
of the caecum. (2) Appendicitis, an inflammation of the ap- 
pendix. (3) Perityphlitis, an inflammation of the serous 
covering of the caecum. 

Etiology. — Typhlitis, or Capitis, is an uncommon disease, 
and usually results from traumatism or fecal impaction (Typh- 
litis stercoralis). Clinically it cannot be distinguished from 
appendicitis. 

Appendicitis is a common affection. Early life, male sex, 
intestinal catarrh, ingestion of irritating food, constipation, 
and previous attacks are predisposing factors. Foreign bodies 
or fecal accumulations in the appendix or traumatism usually 
excite it. 

Perityphlitis is always secondary to appendicitis. 

Pathology. — In grave cases the appendix is thickened, 
injected, ulcerated, or necrosed; and peritonitis or localized 
abscesses are frequently discovered. 

Symptoms. — It may begin gradually or abruptly. The 
usual manifestations are moderate fever (101°-104°) with its 
associated phenomena ; severe pain in the right iliac fossa, 
which is increased by flexing and extending the thigh ; consti- 
pation, and, later, vomiting. 

Physical Signs. — -The patient usually lies with the right 
thigh flexed. 

Palpation elicits tenderness, and sometimes diffuse or cir- 
cumscribed induration. When the appendix is favorably 



INTESTINAL OBSTRUCTION. 59 

situated, a finger in the rectum may detect fulness and indu- 
ration to the right. 

Percussion often yields a dull note. 

Tn some instances the first manifestation is general peri- 
tonitis. It should be borne in mind that abrupt general 
peritonitis without obvious cause is usually due to appendicitis. 

Complications. — (1) Peritonitis by extension or perfora- 
tion. (2) Abscess, pointing externally in the ileo-csecal region, 
in the flank or buttock ; or internally, exciting peritonitis- 

Prognosis. — Always guarded ; cases apparently mild may 
terminate fatally. Mild cases, in which the symptoms are 
probably due to typhlitis, often recover rapidly under appro- 
priate treatment. 

Treatment. — Absolute rest. Liquid diet. The lower 
bowel should be emptied by enemata. Opium should be given 
for the relief of pain. In the initial stage, salines cautiously 
administered may yield excellent results; Epsoni salts (5ij) 
should be given every two hours until two or three watery 
stools have been produced. 

Local Treatment. — An ice-bag may be placed on the ileo- 
cecal region, but if there is much tenderness leeches followed 
by poultices give the most relief. Increasing tenderness and 
induration, a stable or rising temperature, persistent vomiting, 
obstinate constipation, or increasing abdominal tympany will 
each demand surgical interference. Patients subject to recur- 
rent attacks should be scrupulously careful as regards hygiene 
and diet ; they should be habitually clothed in flannel, and 
should wear an abdominal protector. Residence in a dry and 
equable climate sometimes secures immunity. 

A formal operation for the removal of the appendix may be 
considered in these cases. 



INTESTINAL. OBSTRUCTION ; ILEUS. 

Etiology. Acute Obstruction. — (1) Congenital occlusion. 
(2-) Intussusception (Invagination). (3) Strangulation, internal 
or external. (4) Twists (Volvulus) or Knots. 

The following are conditions which produce chronic obstruc- 
tion, though at times the symptoms develop acutely : (1) Stric- 



60 DISEASES OF THE DIGESTIVE SYSTEM. 

tm e from a healed ulcer. (2) Unnatural accumulations, as 
fecal masses (Coprostasis), foreign bodies, gall-stones. (3) 
Tumors, within or without. 

Symptoms. Acute Obstruction. — (1) Sudden pain, at first 

paroxysmal, but later continuous. (2) Constipation. (3) 

- Vomiting, persistent, and becoming fecal (stercoraceous). 

(4) Abdominal distention. (5) Collapse, indicated by pinched 

features, cold extremities, and feeble pulse. 

Chronic Obstruction. — These symptoms develop slowly. 

Congenital Occlusion. — The usual location is the anus or 
rectum. It is detected by direct examination. 

Intussusception, — The slipping of a portion of intestine into 
another portion immediately below it. It is noted chiefly in 
children, and is more common in males. Its exciting cause is 
probably perverted peristalsis, whereby one part of the bowel 
is contracted while the adjacent part is dilated. In rare in- 
stances it has been induced by the traction of intestinal polypi. 
The usual seat is the ileo-csecal region. 

Multiple invaginations are frequently found post-mortem, 
which have resulted from the irregular peristalsis occurring 
just before death ; they possess no inflammatory characteris- 
tics. In invaginations not cadaveric, the parts are injected, 
swollen, and covered with lymph. 

Diagnosis. — The symptoms of obstruction, with the age; 
a " sausage-shaped" tumor in the line of the colon ; the rare 
detection of the invaginated portion in the rectum ; tenesmus : 
and bloody mucous stools are the diagnostic features. 

Prognosis . — Death usually results from gangrene, peri- 
tonitis, or collapse. A favorable termination sometimes results 
from the escape of the incarcerated part, or by a sloughing off 
of the strangulated portion and adhesion of the serous surfaces. 

Strangulation. — This often occurs in external hernia, when 
it can be recognized bv an examination of the inguinal, 
femoral, and umbilical rings. 

Internal Strangulation is due to the slipping of a coil of 
intestine through the diaphragm, foramen of Winslow, an 
abnormal opening in the omentum or mesentery, or a loop of 
inflammatory lymph. 



INTESTINAL OBSTRUCTION. 61 

Diagnosis. — It might be suspected by the absence of other 
cause, by the sudden onset, or by a history of previous 
peritonitis. 

Twist. — Occurs most commonly in middle-aged men. The 
usual seat is the sigmoid flexure. A relaxed and lengthened 
mesentery is a predisposing factor. 

Diagnosis. — Rarely possible. 

Stricture. — Usually results from syphilitic, tuberculous, or 
dysenteric ulcers. The rectum is the most common seat. 

Diagnosis. — History, gradual onset, results of rectal 
examination, and "pipe-stem 7 ' or "ribbon-like" stools are 
diagnostic features. 

Unnatural Accumulations. — Fecal impaction is recognized 
by the gradual onset, mild obstructive symptoms, history of 
constipation, and a painless, irregular, doughy tumor in the 
line of the colon. 

Gall-stones may obstruct the ileum ; the history will aid in 
their recognition. 

Tumors. — The most common tumor within the bowel is a 
cancer ; it is usually located in the sigmoid flexure or rectum. 

Diagnosis. — Age, gradual onset, pain, bloody discharges, 
cachexia, and a tumor in the rectum are the characteristic 
features. 

Tumors of adjacent viscera may compress the bowel. Their 
recognition will depend upon physical examination. 

Treatment. — In all cases of acute obstruction, excepting 
external hernia and congenital atresia, whether the cause is 
apparent or not, observe the following rules : — 

1. Administer opium to relieve pain and check peristalsis. 

2. Apply hot fomentations to the abdomen. 

3. Restrict the diet to liquids in small quantities. Nutri- 
tive enemata should be employed in the weak. 

4. Avoid purgatives. 

5. Elevate the buttocks, insert a rectal tube, and distend 
the colon with from two to six quarts of tepid water, which 
should flow from a reservoir placed from ten to twenty feet 
above the patient. The age will determine the length of the 
tube and the amount of fluid. 

6. When the stomach and upper bowel are distended by 



62 DISEASES OF THE DIGESTIVE SYSTEM. 

gas, washing out of the stomach is useful. (Kiissmaul, Lieber- 
uieister.) 

7. After failure in these methods laparotomy should not 
be delayed ; the earlier its performance the greater the chance 
of success. 

In fecal impaction administer salines and inject water or oil. 
Electricity is sometimes useful. Rectal accumulations may be 
removed by the fingers or a suitable scoop. 

Strictures require surgical interference. 

ANIMAL PARASITIC AFFECTIONS. 
Tape-worms. 

Varieties. — Taenia solium. Taenia saginata. Bothrio- 
cephalus latus. Taenia echinococcus. 

History. — The eggs of the tape-worm are ingested by an 
animal, and embryos, or proscolices, are liberated in the 
stomach ; these migrate to other organs, where they are 
transformed into larvae or scolices. The encysted larva, or 
scolex, is termed a cysticercus ; the condition is known as 
" measles." The mature worm develops in man from the 
cysticercus contained in infected meat. 

Taenia Solium (Pork Tape-worm). — Is derived from the hog, 
and is two or three yards in length.^ The head is the size of 
that of a pin, is provided with four pigmented cup-like 
suckers, surrounded by a double row of hooklets, and is 
attached to the body by a thread-like neck. The sexual ori- 
fice is in the centre of the broad surface of the segment. 

Tsenia Saginata (Taenia Mediocanellatd). — Is derived from 
beef, and is five or six yards in length. The head is larger 
than that of the taenia solium, and has four large suckers, but 
no hooklets. The segments are fatter, and the uterine 
branches are finer and more numerous than in the taenia 
solium. 

Bothriocephalus LatllS. — Is found especially in Europe, 
and is derived from fish. The head has no hooklets, but two 
lateral grooves. The body is very long. The sexual orifice 
is on the narrow side of the segment. 



ANIMAL PARASITIC AFFECTIONS. ' 63 

Symptoms. — Often absent. Frequently there are dyspeptic 
symptoms, colicky pains, loss of flesh, capricious appetite, and 
sometimes reflex nervous phenomena, such as vertigo, palpi- 
tation, " night-terrors," convulsions, itching in the nose, and 
choreic movements. 

The Diagnosis rests on the discovery of the eggs or seg- 
ments in the stools. 

Treatment. — A light diet for a day or two, and a saline 
purge prior to the administration of the anthelmintic. After 
an unsubstantial breakfast administer one of the following 
efficient remedies : Pumpkin seeds (two to three ounces) ; oleo- 
resin of male fern (3j-ij)> pelletierine, the alkaloid of pome- 
granate (gr. v) ; Kooso (3ss). 

J$l Oleoresin. filicis, f^j ; 

Pulv. acacise et sacchar., aa q. s. 
Aquae cinuamomi, q. s. ad f^ij. — M. 
Sig.— One tablespoonful, repeated if required. 

A purge should be given a few hours after the vermifuge. 
The treatment is successful only when the head is passed. 

Nematodes. 

AscariS Lumbricoides (Bound Worms). — Life history un- 
known. They are of a pale-pink color, and in form resemble 
earth-worms. They inhabit the small intestines, but occa- 
sionally migrate into other organs, viz., stomach, bile-ducts, 
and larynx. They are most commonly found in children. 

Symptoms. — Often absent. Sometimes there are dyspepsia, 
mucous stools, colicky pains, voracious appetite, ansemia, and 
reflex nervous phenomena, as " night-terrors," grinding of the 
teeth, pruritus of nose and anus, choreic movements, and con- 
vulsions. 

Treatment — Santonin (gr. J-gr. iij) ; worm-seed oil (gtt. x 
in capsule or on sugar) ; fluid extract of spigelia (f 5j-f3h'j), 
are efficient remedies. 

^ Santonini, gr. vj ; 

Hydrarg. chlor. mit., gr. vj ; 

Sacchari.. gr. xxiv ; 
M. et ft. chart. No. xij. (Stark.) 
Sig. — One powder morning and evening. 



64 DISEASES OF THE DIGESTIVE SYSTEM. 

Oxyuris VermiculariS (Seat-worm, Pin-worm). — This is a 
small worm, most commonly seen in children, and occupies 
the colon and rectum. It produces intense itching of the 
anus, which is worse at night. It may migrate into the 
vagina and excite pruritus or vaginitis, and lead to mastur- 
bation. 

Treatment. — An injection of water, followed by the in- 
jection of two or three ounces of an infusion of quassia chips 
(3ij-iij to the pint). 

AnchylostOBlUHl Duodenale. — A small worm, not uncom- 
mon in the north of Europe and Egypt. It has been detected 
most frequently in miners and brickmakers, who are probably 
infected by drinking water containing the eggs of the parasite. 
The worm inhabits the small intestine. 

Symptoms. — Dyspepsia and intense anaemia. The latter 
has been termed Egyptian chlorosis, and may be recognized by 
the detection of eggs in the stools. 

Treatment. — Santonin, male fern, and thymol have been 
recommended. 

TricocephalllS Dispar ( Whip-worm). — A small worm, thick 
at one end and thread-like at the other. It occupies the colon 
and caecum, and produces but little disturbance. 

Filaria Sanguinis Hominis. — A small thread-like worm, 
most commonly seen in the tropics. The adult occupies the 
lymphatics, and the female brings forth a great number of 
embryos, which soon find their way into the blood-current. 
It is noteworthy that they may be detected in the blood at 
night but not during the day. The medium of infection is 
probably the mosquito, which carries the embryo from the 
blood to the water. 

Symptoms. — Often absent. Chyluria, hematuria, and 
lymph-scrotum sometimes result from lymphatic obstruction. 

Trichina Spiralis.— A small worm derived from the hog. 
Man is infected by eating insufficiently-cooked pork contain- 
ing the encapsulated worm. The worm is set free in the 
stomach, where it develops and brings forth living embryos. 
These soon migrate into the muscles, where they in turn de- 
velop, coil themselves up, and become encapsulated. Trich- 
inous capsules, impregnated with lime-salts, are visible to 






PERITONITIS. 65 

the naked eye, and are sometimes detected accidentally at 
autopsies. 

Symptoms of Trichinosis. — Sometimes absent. When 
large numbers have been ingested, gastro-intestinal symptoms 
develop in a few days. These are : Pain, nausea, vomiting, 
and serous diarrhoea. 

Muscular Symptoms. — In from one to two weeks muscular 
symptoms develop. The muscles become swollen, firm, ex- 
tremely tender and painful. Movement is inhibited, and 
dyspnoea results from the involvement of respiratory muscles. 
(Edema, especially of the face, is a prominent symptom. Pro- 
fuse sweating is sometimes observed, and high fever is com- 
monly present. 

Prognosis. — Depends on the number of worms ingested. 
The majority of patients recover. 

Treatment. — Prevent by thoroughly cooking all pork 
products. In the first stage use purgatives. After migration 
employ opium, warm fomentations, and stimulants. 

PERITONITIS. 

Definition. — Inflammation of the peritoneum. 

Varieties. — According to cause, it may be primary or 
secondary ; according to extent, local or general ; according to 
time, acute or chronic ; and according to the exudate, sero- 
fibrinous, fibrinous, or purulent. 

Etiology. — Acute peritonitis may be: (1) Idiopathic, 
arising from exposure to cold and wet (rare). (2) Traumatic. 
(3) Perforative, resulting from a perforating wound, or the 
rupture of a gastric, typhlitic, typhoid, or dysenteric ulcer, or 
a visceral abscess. (4) Secondary to inflammatory disease of 
adjacent viscera, as septic endometritis and typhoid fever. 
(5) Secondary to some general morbid process, as rheumatism, 
Bright' s disease. 

Pathology. — In the first stage the membrane is rod, 
sticky, and lustreless; later, a sero-fibrinous, fibrinous, or puru- 
lent exudate is formed. In some cases the exudate is tinged 
with blood. 
5 



66 DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms. Acute General Peritonitis. — Chill ; moderate 
fever (102°-130°), with its associated phenomena ; a rapid, 
wiry pulse ; abdominal pain and tenderness so intense that 
abdominal respiration and body movements are inhibited ; the 
patient lies on his back with his thighs flexed ; the features 
are pinched ; the vomiting is persistent ; the bowels are con- 
stipated. 

Inspection reveals great abdominal distention. 

Palpation elicits tenderness, and rarely a friction fremitus. 

Percussion at first yields universal . tympany ; but later, 
d illness in the flanks from the gravitation of the exudate. 

Diagnosis. Acute Enteritis. — Pain and tenderness not so 
marked, absence of wiry pulse, and diarrhoea instead of con- 
stipation. 

Intestinal Obstruction. — Unless associated with peritonitis, 
there is no fever, no wiry pulse, nor extreme tenderness ; the 
vomiting becomes fecal. 

Hysterical Abdomen. — This condition may resemble peri- 
tonitis in all particulars. The sex and personal history must 
be considered. Fever is not usually present, the pulse is not 
rapid and wiry ; when the attention is distracted the pain may 
vanish. 

Prognosis. — Generally unfavorable. Death usually results 
in a few days from exhaustion. When the process is neither 
septic nor extensive recovery frequently follows. 

Treatment. — Restrict the diet. Administer opium in full 
doses to check peristalsis and relieve pain. In severe cases 
the drug may be pushed until the respiration has been reduced 
to twelve per minute; apply leeches to the abdomen, and fol- 
low with light poultices. In some cases cold cloths are more 
grateful than warm applications. In non-perforating cases, 
salines, as Epsom or Rochelle salts (3ij)> niay be given until 
bowels move freely. These salts, while not increasing peri- 
stalsis, attract serum from the turgid bloodvessels, and so 
relieve congestion. In perforating cases — and these are the 
most frequent — laparatomy offers the only hope of cure. 



ASCITES. 67 



Chronic Peritonitis. 

Etiology. — It is usually tuberculous; it may be cancerous ; 
it may be syphilitic (occurring in young children); it rarely 
follows Bright's disease, it rarely follows an acute attack; 
it occurs in chronic alcoholism. 

Pathology. — The intestines are matted together by bands 
of fibrous lymph. The omentum is often contracted and 
greatly thickened. Effusion is usually present, but it varies 
greatly in amount; in the tuberculous and cancerous varieties 
it may be bloody. 

Symptoms. — Fever is often absent. Pain is not severe, 
and is commonly paroxysmal. There is usually diffuse 
tenderness. 

Inspection. — The abdomen is generally distended; often 
irregularly, from sacculated effusions, inflated intestinal coils, 
or the projecting matted omentum. 

Palpation may detect a friction fremitus, and the irregulari- 
ties noted above. The resistance is often great. 

Percussion. — Dulness in the flanks with superincumbent 
tympany. When the fluid is sacculated, the dulness may be 
irregularly distributed. Fluctuation can sometimes be elicited. 

Prognosis. — Unfavorable. 

Treatment. — Pest. Light diet and nutrient tonics (malt, 
cod-liver oil). Iodide of potassium is given for its absorbent 
effect. Iodine may be applied externally. When the effu- 
sion is great, paracentesis will be required. 

ASCITES. 

Definition. — A collection of serous fluid in the perito- 
neal cavity. 

Etiology. — (1) It may result from one of the common 
causes of dropsy, viz: Bright's disease, chronic heart disease, 
chronic lung disease, anaemia, and especially cirrhosis of the 
liver. (2) Pressure of a tumor or displaced viseus upon the 
portal vein. (3) Chronic peritonitis. (4) Pressure upon the 
thoracic duct (Chylous ascites). 



68 DISEASES OF THE DIGESTIVE SYSTEM. 

Symptoms. — When the effusion is large, a sensation of 
weight, dyspnoea, scanty urine, constipation, and oedema of 
the feet usually result from pressure. 

Physical Signs. Inspection. — The abdomen is distended, 
the surface is smooth aud shining; the base of the thorax is 
broadened ; the navel is more or less obliterated ; the super- 
ficial veins are frequently enlarged ; aud, when the patient lies 
in the dorsal position, the flanks bulge. 

Palpation may elicit fluctuation, aud in the flanks a sense 
of resistance. 

Percussion. — Dulness aud resistance in dependent parts, 
with superincumbent tympany. Dulness is movable; it is 
detected in the flanks when the patient occupies the dorsal 
position. 

Aspiration. — The fluid is usually clear, straw-colored, and 
albuminous; the specific gravity is from 1012-1016. 

Diagnosis. Tynipanites, or meteor ism. — This yields uni- 
versal hyper-resonance on percussion. 

Ovarian Cysts. — The enlargement begins in the iliac fossa. 
The dulness is more or less immovable; as the intestines are 
pushed aside, there is dulness anteriorly, instead of tympany, 
as in ascites. Vaginal examination furnishes important data; 
the fluid has a higher specific gravity and often coagulates 
spontaneously. 

Distention of the Bladder. — The location of the dulness and 
resistance, the history, and the results of catheterization will 
render the diagnosis apparent. 

Treatment. — When possible, endeavor to remove the 
cause. Encourage free catharsis by the use of concentrated 
saline solutions, compound jalap powder (gr. xx-xxx), ela- 
terium (gr. J). Encourage free diuresis by the use of citrate 
of caffeine (gr. iij-v), infusion of digitalis (fiss), or Xiemeyei^s 
pill (page 00). 

J$l Potassii citrat., £ss ; 
Tine, scillse, f ^ss ; 
Inf. digitalis., f.^iij ; 
Aqua?, q. s. ad f^vj. — M. 
Sig. — A tablespoonful thrice daily. 

If the effusion is very large, if the stomach is irritable, or 



DISEASES OF THE PANCREAS. 69 

if internal remedies fail to give relief, tapping will be 
required. 

DISEASES OF THE PANCREAS. 

Until very recent years pathological conditions of the pan- 
creas have excited little attention, but careful study reveals the 
fact that the organ is not infrequently the seat of definite 
lesions which excite well-marked clinical phenomena; how- 
ever, in the present state of medical science these phenomena 
can rarely be attributed to their true cause. In chronic pan- 
creatic affections, wasting, fatty stools, and glycosuria are 
notable symptoms. 

Pancreatic Apoplexy. — A profuse hemorrhage excites sud- 
den pain in the pancreatic region, vomiting, abdominal disten- 
tion, and symptoms of collapse. It is almost invariably fatal. 

Acute Pancreatitis. — Causes unknown. The pancreas is 
enlarged, ecchymosed, and sometimes the seat of fatty degene- 
ration or abscesses. The symptoms are pain, fever, vomiting, 
and collapse. 

Cirrhosis of the P 'ancreas (Chronic Interstitial Pancreatitis). 
— It probably results from the conditions which induce 
hepatic cirrhosis, viz., alcoholism, syphilis, etc. The pancreas 
is contracted and hardened, and microscopic examination 
reveals an overgrowth of connective tissue with atrophy of the 
secreting cells. Glycosuria, fatty stools, and inanition have 
been attributed to it. 

Pancreatic Calculi. — Concretions from the pancreatic juice 
sometimes lodge in the duct of Wirsung and excite colic ; 
their permanent impaction leads to the formation of cysts. 

Cancer of the Pancreas. — May be primary or secondary. 
The most common seat is the head ; the most common variety 
is the scirrhus. 

Symptoms. — Pain, rapid emaciation, fatty stools, an im- 
movable tumor which often receives a pulsation from the 
underlying aorta ; sometimes jaundice and glycosuria. 



70 DISEASES OF THE DIGESTIVE SYSTEM. 



DISEASES OF THE LIVER. 

The liver is situated in the right hypochondrium, with a 
small part projecting through the epigastrium to the left hypo- 
chondrium. 

Area of Liver iJulness.- — The absolute dulness (part un- 
covered by lung) extends in the mammary \[ne from the upper 
border of the sixth rib to the costal margin ; in the axillary 
line, from the eighth rib to the eleventh rib ; in the scapular 
line, from the ninth rib to the eleventh rib ; in the median 
line, the upper border is lost in the cardiac dulness, while the 
lower border lies midway between the ensiform cartiln^e and 
the umbilicus. Slight dulness in the mammary line begins at 
the fifth rib. 

Palpation. 

Palpation of the liver is practised to determine position, 
size, form, and consistence ; and to detect any tenderness or 
pulsation. 

Conditions in which the liver is palpable: — 

1. In thin subjects, the edge is sometimes palpable under 
normal conditions. 

2. In very young children, in whom the liver is always 
proportionately large. 

3. In depression of the liver, as by a pleural effusion. or by 
a consolidated lung. 

4. When the suspensory ligament is relaxed and the liver 
" wanders." 

5. In enlargement from any cause. 

6. In certain abnormalities of form, as in the " tight-lace 
liver." 

Superficial Irregularities. — Small irregularities may be 
noted in cancer, syphilis of the liver, and atrophic cirrhosis. 

Large prominences are sometimes noted in tumors, abscesses, 
and hydatid cysts. 

Consistence. — The liver is firm to the touch in hypertropl 
cirrhosis, cancer, congestion, and amyloid disease. In ab: 



.cess 



JAUNDICE OR ICTERUS. 71 

and hydatid disease the resistance is less marked, and some- 
times fluctuation can be noted. 

Tenderness. — The liver is tender in acute congestion, abscess, 
cancer, and in affections complicated with perihepatitis. 

Pulsation may be detected in the venous congestion resulting 
from tricuspid regurgitation, abdominal aneurism, in tumors 
of the left lobe resting on the aorta, rarely in aortic regurgi- 
tation. 

Percussion. 

Percussion determines size and resistance. 

The liver is uniformly enlarged in : (1) Congestion, active 
and passive. (2) Fatty infiltration. (3) Amyloid infiltration. 
(4) Hypertrophic cirrhosis. (5) Hypertrophy as in leucaemia 
and diabetes. 

Irregular enlargements of the liver are noted in : (1) Cancer. 
(2) Abscess. (3) Hydatid disease. (4) Syphilis. 

The liver is diminished in size in : (1) Atrophic cirrhosis, 
late stage. (2) Fatty degeneration. (3) Acute yellow atrophy. 
(4) Senile atrophy. The area of hepatic dulness may be 
diminished from certain extrinsic causes, namely, pulmonary 
emphysema and excessive tympanites. 

JAUNDICE OR ICTERUS. 

Definition. — Pigmentation of the tissues and secretions 
with bile-pigments. 

Varieties. — (1) Hepatogenous, or obstructive jaundice. 
(2) Hematogenous, or non-obstructive jaundice. 

Etiology of Hepatogenous Jaundice. — Obstruction 
to the outflow of bile leads to its accumulation and re-absorp- 
tion. 

Obstruction may be due to the following causes : — 

1. Stricture of the bile-duct, congenital or acquired. 

2. Catarrh of the bile-ducts, or of the duodenal mucous 
membrane around the orifice of the ductus choledochus. 

3. Foreign bodies in the ducts ; as gall-stones, parasites. 

4. Tumors of the liver or of adjacent viscera compressing the 



72 DISEASES OF THE DIGESTIVE SYSTEM. 

ducts. Fecal accumulations, a pregnant uterus, and displaced 
organs may similarly compress the ducts. 

5. Lowered blood pressure in the vessels of the liver causing 
increased tension in the bile-ducts, as in the simple icterus of 
the newborn. (Frerichs.) 

Symptoms. — The skin, mucous membranes, and secretions 
are stained yellow. The discoloration is usually first noticed 
in the conjunctivae. The stools are light, the urine is dark, 
and in bad cases resembles porter. The pulse is usually slow, 
and the temperature slightly subnormal. There is always some 
mental depression, and in extreme cases delirium, convulsions, 
and coma may develop. Itching of the skin is often noted, 
and urticaria is a common complication. In grave cases sub- 
cutaneous ecchymoses may appear. 

Diagnosis. — Other discolorations, like the bronze hue of 
Addison's disease, and the green tint of chlorosis, must be dis- 
tinguished from jaundice ; but in those cases the conjunctiva 
is white and the urine lacks bile. 

Etiology of Hematogenous oe Xox-obstructiye 
Jaundice. — This form results from a disintegration of the 
blood, or a destruction of the liver substance. It is sometimes 
noted in pernicious anaemia, and other grave anaemias, but it 
more commonly results from the action of some toxic agent on 
the blood; thus, it may be observed in poisoning by phos- 
phorus, arsenic, and other minerals; in snake-poisoning, in 
pvaemia, and in certain infectious fevers — as yellow fever, re- 
lapsing fever, malarial fever, and acute yellow atrophy. 

Symptoms. — Much the same as in obstructive jaundice, but 
the staining of the skin is usually not so intense, the stools 
still contain bile, and grave cerebral symptoms are more apt 
to develop. 

ICTERUS XEOjS ATORU3I. 

Physiological icterus in the newborn is slight, and probably 
results from the lowered pressure in the portal vessels caused 
by ligation of the umbilical vein, and the subsequent absorp- 
tion of bile from the tense capillary ducts. 

Pathological icterus in the newborn is marked, and com- 



CATARRHAL JAUNDICE. 73 

inonly proves fatal. It results from congenital stricture of 
the duct, syphilis of the liver, or septic infection through the 
umbilical vein. 

ACHOLIA. 

(Choleemia, Cholestereemia.) 

This term is applied to a group of symptoms noted in dis- 
eases associated with a destruction of the hepatic substance, 
and probably dependent upon the retention of poisons which 
should have been eliminated by the liver. 

Etiology. — Acholia occurs in acute yellow atrophy, and 
sometimes at the close of cancer, cirrhosis, and fatty degene- 
ration of the liver. 

Symptoms. — Delirium, convulsions, stupor, and coma. 
Jaundice may or may not be present. Subcutaneous ecchy- 
moses and hemorrhages from mucous membranes are frequently 
observed. 

CATARRHAL JAUNDICE. 

(Catarrhal Hepatitis, Catarrh of the Bile-ducts.) 

Etiology. — (1) The most common cause is the extension 
of a gastro-duodenal catarrh into the ducts. (2) Primary in- 
flammation of the ducts may result from exposure to cold and 
wet. (3) It may be induced by irritation from gall-stones. 
(4) It may be infectious, complicating malaria, pneumonia, 
relapsing fever, and similar diseases. 

Pathology. — The large ducts are particularly affected ; 
the mucous membrane is swollen and covered with tenacious 
mucus. When the gall-bladder is compressed, bile is ejected 
with less ease than is natural through the duodenal orifice. 
When the catarrhal process is long-continued, ulceration of 
the ducts, or secondary cirrhosis (biliary cirrhosis) may result. 

Symptoms. — (1) Symptoms of gastro-duodenal catarrh 
usually precede. These arc : Coated tongue, anorexia, fetid 
breath, epigastric distress, vomiting, and perhaps diarrhoea. 
(2) Obstructive jaundice, indicated by yellow skin and con- 
junctivae, light stools, and dark urine. (3) In acute cases. 



74 DISEASES OF THE DIGESTIVE SYSTEM. 

slight fever and swelling of the liver, which is tender to the 
touch. 

Diagnosis. — Usually easy ; the exclusion of other causes 
of jaundice, and the consideration of the age, acute onset, and 
preservation of health will usually make the diagnosis appa- 
rent. 

Prognosis. — Favorable. It rarely becomes chronic, and 
leads to biliary cirrhosis and ulceration of the ducts. The 
average duration is from a few days to several w^eeks. 

Treatment. — Rest. Liquid diet. Stupes of turpentine 
or of dilute nitrohydroehloric acid may be applied locally. 
Mild laxatives are often indicated ; calomel may be selected. 

!£. Hydrarg. chlor. mit., gr. ij ; 
Sodii bicarb., ^j. — M. 
Ft. in chart. No. xii. 
Sig. — One every hour until a laxative effect is produced. 

For the gastro-duodenal catarrh, mineral waters^ subnitrate 
of bismuth (gr. xx), nitrate of silver, (gr. jr q. d.), chloride of 
ammonium (gr. x, q. d.), phosphate of sodium (3j q. d.), are 
valuable adjuncts. In persistent cases the daily irrigation of 
the bowel with cold water (1-2 quarts) has been highly recom- 
mended ; the injections stimulate peristalsis and thus favor the 
expulsion of mucus and bile from the ducts. 



BILIARY CALCULI. 

(Gall-stones, Cholelithiasis.) 

Definition. — Concretions formed in the gall-bladder, and 
composed for the most part of bile-elements. 

Etiology. — Female sex, age (after forty), heredity, seden- 
tary habits, a rich diet, diseases of the liver which obstruct 
the flow of bile, as tumors, and catarrh of the ducts. 

Pathology. — The stones may be found in the ducts, but 
they are always formed in the gall-bladder. There may be 
one or several hundred. When multiple, they are found with 
facets, from attrition. The size varies from a grain of sand to 
a large walnut. The color varies from a light yellow to a 
dark green. The chief constituent is cholesterin, but bile- 



BILIARY CALCULI. 75 

acids, bile-pigments, lime, and magnesia also enter into their 
composition. On section, they usually present a concentric 
arrangement. The pathogenesis is not known ; a chemical 
change in the bile probably leads to a precipitation of the 
eholesterin. 

Event*. — (1) Stones often remain latent in the bladder. (2) 
They may pass out with pain and spasm (biliary colic). (3) 
Impaction. A stone may obstruct the cystic duct and lead to 
distention of the bladder with mucus. More frequently the 
common duct is obstructed near its duodenal orifice, when the 
following symptoms result : Permanent jaundice, tenderness, 
exacerbations of pain, and peculiar paroxysms of fever, chills, 
and sweats, resembling malaria (Charcot's intermittent). Such 
paroxysms are not necessarily dependent on suppuration, 
although abscess may follow obstruction. (4) Perforation 
into the abdominal sac, stomach, or intestine. External per- 
foration is very rare. (5) After exit, stricture of the duct 
may result from ulceration, or intestinal obstruction, from 
impaction. 

Symptoms of Biliary Colic. — Sudden and intense pain 
over the liver, radiating to the back and to the right shoulder. 
It usually occurs an hour or two after eating. A rigor with 
fever may mark the onset. The symptoms of intense pain 
are obvious — anxious face, cold sweat, feeble pulse, and vomit- 
ing. Jaundice may follow from obstruction. If the stone 
escapes, it may be found in the stool. 

Diagnosis. Renal Colic. — Pain radiates from the kidney 
down the ureter to the penis ; blood in the urine ; no jaundice. 

Intestinal Colic. — Pain radiates from the umbilicus; flatu- 
lence ; no jaundice, no stone recovered. 

Gastralgia. — Pain referred to stomach and back ; no jaun- 
dice ; no stone recovered. 

Prognosis. — The attack usually ends favorably. Recur- 
rence is common. The prognosis, as regards ultimate recovery, 
should be guardedly favorable ; complications are comparatively 
rare. 

Treatment. The Attack. — Hot fomentations. Morphia 
(gr. J to J) with atropia (gr. y-J-g-) hypodermically. In aggra- 
vated cases anaesthetics will be required. 



76 DISEASES OF THE DIGESTIVE SYSTEM. 

The Interval. — A regulated diet, largely vegetable. System- 
atic exercise should be enjoined. The flow of bile should be 
encouraged by the use of mineral waters, phosphate of sodium, 
or vegetable eholagogue, like podophyllin or euonymin. Catarrh 
of ducts should be relieved so that stones may escape. 

In impaction the same treatment is indicated with counter- 
irritation, and the use of some intestinal antiseptic, such as 
salol, naphthol, or the salicylate of bismuth, to replace the 
antiseptic elements of the bile. 

In aggravated cases an exploratory incision should be made, 
when a stone may be removed from the common duct (chole- 
dochotomy), or from the gall-bladder (cholecystotomy), or the 
gall-bladder removed (cholecystectomy). 



HYPEREMIA OF THE LIVER. 

Varieties. — (1) Active hyperemia. (2) Passive hyper- 
emia. 

Etiology. — Active hyperemia is commonly due to dietetic 
indiscretions (biliousness). It may result from over-indulgence 
in alcohol. It is often present in the infectious fevers. It 
appears to arise idiopathieally in hot climates. 

Passive hyperemia results from diseases which obstruct the 
venous circulation, as chronic heart and lung disease. 

Pathology. — The liver is enlarged and filled with blood. 
In the passive variety, the centre of the lobule, the area of the 
hepatic vein, is deeply pigmented, while the periphery, the 
area of the portal vein, is pale. This mottled appearance has 
given rise to the term " nutmeg liver." In persistent cases, 
pigmentation, atrophy of liver-cells, and overgrowth of con- 
nective tissue result — a condition termed " cyanotic indura- 
tion." 

Symptoms. Active hypercemia. — It is associated with gastric 
catarrh, and the usual symptoms are : Coated tongue, fetid 
breath, anorexia, pain and tenderness in the epigastric and 
hypochondriac regions, nausea, vomiting, sick-headache, and 
sometimes slight jaundice. The liver may be enlarged 

In the passive variety, the symptoms are the same, though 



CIRRHOSIS OF THE LIVER. 77 

less marked. The liver is often quite large, and in extreme 
cases, such as follow tricuspid regurgitation, it may pulsate. 

Prognosis. — In simple active congestion the prognosis is 
good. In passive congestion the prognosis depends on the 
cause. 

Treatment. Active hypercemia from dietetic errors — Re- 
strict the diet, apply counter-irritants, and administer calomel 
and soda, thus : — 

i$i_ Hydrarg. chlor. mit., gr. j ; 
Sodii bicarb., 3j. — M. 
Ft. hi chart. No. vi. 
Sig. — One every hour until three or four have been taken. 

Follow the calomel with a laxative dose of sodium phosphate 
(3\j-5\j) ; Carlsbad, or Rochelle salts. 

In recurring attacks of biliousness, in addition to dietetic 
and hygienic directions, the following will prove useful : — 

T$l Mass. hydrarg., gr. v; 
Pulv. rhei et 
Ext. gentian., aa gss ; 

Ol. caryophyll. gtt. iv. — M. (Hartshorne.) 
Div. in pil. No. xx. 

Sig. — One or two occasionally, as directed ; to be continued if re- 
quired, thrice daily for several days. 

In passive congestion, direct the treatment to the original 
disease. In mild cases the mineral waters do well (Carlsbad, 
Congress, and Friederichshall). A mercurial laxative may be 
used from time to time. In obstinate cases the concentrated 
salines may be employed as purgatives, and wet cups applied 
to the liver. 

CIRRHOSIS OF THE LIVER. 

(Hob-nailed Liver, Interstitial Hepatitis, Gin-drinker's Liver.) 

Definition. — A chronic disease characterized anatomically 
by a hyperplasia of the connective tissue and destruction of 
the secreting cells, and manifested chiefly by symptoms of 
portal obstruction. 

Etiology. — Male sex and middle life are generally predis- 
posing factors. (1) The abuse of spirituous liquors is a com- 



78 DISEASES OF THE DIGESTIVE SYSTEM. 

mon cause. (2) It follows chronic diseases which alter the 
crasis of the blood, viz : Syphilis, gout, malaria, and tubercu- 
losis. (3) It results from the passive congestion induced by 
chronic heart and lung disease. (4) It may be secondary to 
inflammation of the bile-ducts. It is sometimes seen in 
children ; and in them, congenital syphilis and the infectious 
fevers appear to be the exciting causes. 

Pathology. — Two varieties have been recognized: (1) 
Atrophic cirrhosis, and (2) hypertrophic cirrhosis. 

Atrophic Cirrhosis. — In the early stages the liver is some- 
what large from hyperemia. In the advanced stage the 
liver is small, firm, gray in color, and covered with numerous 
granulations (" hob-nails"). A section of the liver presents 
a network of fine and of coarse pearly bands of connective 
tissue. The contraction of this connective tissue is responsi- 
ble for the reduction in size and granular surface. 

Histology. — An overgrowth of connective tissue ; and, 
from interference with nutrition, fatty infiltration, fatty de- 
generation, atrophy of cells, and pigmentation. 

Hypertrophic Cirrhosis. — This term has been applied to the 
first stage of the atrophic form, and to a large liver resulting 
from the combination of cirrhosis with fatty infiltration. 

More recently, the term hypertrophic, or biliary cirrhosis, 
has been restricted to a condition in which the connective- 
tissue hyperplasia starts from the periphery of the capillary 
bile-ducts instead of from the ramifications of the portal vein, 
as in atrophic cirrhosis. 

As might be expected, the symptoms of portal obstruction 
are not marked, but jaundice is a prominent feature. 

The liver is large, yellow in color, and its surface is smooth 
or finely granular. The increased size is due to a great over- 
growth of connective tissue, and to preservation of the hepatic 
parenchyma. 

Symptoms. — Obstruction to the portal circulation induces 
congestion of the stomach and intestines, and hence the initial 
symptoms are those of gastro-intestinal catarrh. These are : 
Coated tongue, anorexia, fulness and distress after eating, 
vomiting of frothy mucus, flatulence, constipation, and dark 
urine. These phenomena may last for months or years. 



CIRRHOSIS OF THE LIVER. 79 

As the obstruction becomes greater, the portal blood finds 
new channels, and the superficial abdominal veins enlarge, 
notably around the umbilicus, forming the so-called " caput 
medusae." Hemorrhoids result from the same cause. 

Engorgement of the portal system leads to ascites and swell- 
ing of the feet, to hemorrhage from the stomach, bowel, or some 
distant organ, and to enlargement of the spleen. 

Physical Examination. — The liver is at first large, but is 
subsequently contracted. 

There is loss of flesh and strength. The skin is muddy in 
appearance. Jaundice is not common, and when present, 
results from catarrh of the bile-ducts. Death results from 
exhaustion, hemorrhage, intercurrent disease, or from a group 
of cerebral symptoms (delirium, convulsions, and coma) which 
are probably due to the retention of some toxic agent which 
the liver should eliminate. 

Hypertrophic Cirrhosis. — Jaundice is marked. The liver is 
enlarged, smooth, and firm. Symptoms of portal obstruction, 
such as dropsy and hemorrhages, are not marked. The spleen 
is swollen. The disease may last one or two years, but an abrupt 
termination in convulsions and coma may occur at any time. 

Complications. — Tuberculosis, intestinal nephritis, cardiac 
hypertrophy, and hemorrhage. 

Diagnosis. — In the early stage the diagnosis can only be 
suspected. In the drunkard, chronic gastric catarrh with en- 
largement of the liver would strongly indicate cirrhosis, 

Cancer. — History, greater cachexia, jaundice more common, 
and ascites less frequent, liver enlarged and studded with 
nodules, other organs affected, pain, and short duration. 

Chronic Peritonitis with effusion. — This is usually tuberculous 
or cancerous. The short duration, the abdominal tenderness, 
the lack of a uniform enlargement from bands of lymph, the 
absence of symptoms indicating portal obstruction, the normal 
size of the liver, after tapping, and the turbid sanious fluid 
will indicate chronic peritonitis. 

Prognosis. — Unfavorable. It may be arrested in the early 
stage. The entire duration may be many years, but death 
usually results in from one to three years after symptoms of 
portal obstruction have appeared. 



80 DISEASES OF THE DIGESTIVE SYSTEM. 

Teeatmext. — Light nutritous diet. Rest. Alcohol must 
be interdicted. Treat the gastric catarrh with nitrate of silver, 
bismuth, mineral waters, and antiseptics (creasote and salicylate 
of bismuth). Iodide of potassium in small doses, well diluted, 
may be of service in the early stage. Counter-irritation over 
the liver should be frequently practised. 

Ascites. — Concentrated saline purges in the morning (p]psom 
salts Iss in enough water to dissolve it). Diuretics, as digitalis 
or caffeine. Xiemeyer's pill may be useful. 

]£ Mass. hydrarg., gr. xij ; 
Pulv. digitalis, gr. xij ; 
Pulv. scillae, gr. xij. — M. 
Ft. in pil. No. xii. 
Sig. -One pill thrice daily. 

When the effusion is very large, internal remedies fail, and 
paracentesis will be required. 

The Operation. — Empty the bladder. Anaesthetize a point 
in the linea alba midway between the umbilicus and pubis. 
Tap Avith a small trocar, and have a long rubber tube at- 
tached to the canula for conveying the liquid into a conve- 
nient receptacle. When the liquid stops flowing withdraw the 
canula, cover the wound with adhesive plaster, and apply an 
abdominal binder. Observe strict antisepsis. The operation 
is free from danger. 

ABSCESS OF THE EXVER. 

Etiology. — (1) The presence in the liver of the amoeba coli 
of dvsentery. (2) Traumatism. (3) Foreign bodies, gall- 
stones, retained bile, and hydatid cysts. (4) Septic emboli ; 
they may come through the hepatic artery, but usually they 
come through the portal vein from gastric ulcers, or the ulcers 
of dysentery, typhlitis, or typhoid fever, and produce a puru- 
lent inflammation of the vein (suppurative pylephlebitis). 

Pathology. — The abscess following amoebic dysentery is 
often single, and usually occupies the right lobe. 

Embolic abscesses are always multiple. 

Events. — Hepatic abscess may kill by exhaustion or by 
rupture into adjacent viscera. Recovery may follow after 






CANCER OF THE LIVER. 81 

operation or spontaneous evacuation ; and the latter may be 
external through the bronchial tubes or through the bowel. 

Symptoms. — Hectic symptoms : Fever, high in the evening 
and low in the morning, sweats, and chills. Local symp- 
toms : The liver is enlarged, painful, and tender. There may 
be bulging and even fluctuation. Pus may be detected by the 
aspirating needle. Jaundice from obstruction is sometimes 
present. 

Diagnosis. Hydatid Cysts. — Long duration, history, clear 
fluid on aspiration, absence of pain, and absence of hectic 
symptoms. 

Cancer. — History, cachexia, the involvement of other organs, 
multiple and firm nodules, and absence of hectic symptoms. 

Intermittent Fever due to impacted calculi. — Periodic, of long 
duration, absence of fever in the intervals, and fair preserva- 
tion of health. 

Prognosis. — Embolic abscesses (multiple) prove invariably 
fatal. Traumatic abscesses, or abscesses due to a amoebic 
dysentery may terminate favorably after spontaneous or in- 
duced evacuation. 

Treatment. — Hot applications, opium, quinine, and stimu- 
lants. When the history indicates a single abscess, invoke sur- 
gical aid. 

CANCER OF THE LIVER. 

Etiology. — Male sex, age (after forty), heredity, and trau- 
matism are predisposing factors. 

Pathology. — It is generally secondary. The liver is en- 
larged, and studded with numerous grayish-white nodes, some 
of which project from the surface. The superficial nodes are 
often depressed at the centre. 

Symptoms. — (1) Severe pain and tenderness. (2) Cachexia, 
i.e. loss of flesh and strength, with pallor. (3) Pressure- 
symptoms: jaundice is common but ascites is rare. (4) Phy- 
sical examination : the liver is enlarged, its surface is nodular, 
and the central depression, or umbilications, can often be 
detected. (5) Symptoms of the primary growth, which is 
usually in the stomach. 



k2 DISEASES OF THE DIGESTIVE SYSTEM. 

Fever is generaly absent, but secondary perihepatitis or 
suppuration of the cancerous nodules may induce it. 

Diagnosis. Hypertrophic Cirrhosis. — Liver is smooth and 
painless, the duration is longer, cachexia is not marked, and 
there is no indication of a primary cancer. 

Hydatid Cysts. — Health preserved, tumor elastic or fluctuat- 
ing, no pain, jaundice uncommon, aspiration yields a clear 
fluid containing hooklets. 

Abscess. — History, short duration, hectic fever, and results 
of aspiration. 

Prognosis. — Absolutely fatal. Duration, from a few 
months to a year. 

Treatment. — Palliative. 

AMYLOID LIVER. 

(Waxy Liver, Lardaceous Liver.) 

Definition. — An enlargement of the liver due to the de- 
position of an albuminoid substance. 

Etiology. — (1) Prolonged suppuration ; (2) syphilis ; (3) 
tuberculosis, and (4) chronic malaria are causal factors. 

Pathology. — The liver is very large, hard, and smooth. 
The edge is blunt. On section, the surface is " waxy," and a 
dilute solution of iodine strikes a mahogany-red color with the 
amyloid material. The degenerative process begins in the 
walls of the capillaries and spreads to the connective tissue. 

Symptoms. — Failure of general health with anaemia. The 
liver is enlarged, smooth, firm, and painless, and presents a 
blnnt edge. The spleen and kidneys share in the degeneration, 
and, as a result, the spleen is enlarged and the urine is albu- 
minous. 

Diagnosis. — The history, the smooth, painless, enlarge- 
ment of the liver without jaundice, and the involvement of the 
kidneys and spleen, are the diagnostic phenomena. 

Prognosis. — Unfavorable. 

Treatment. — Remedies must be directed to the causal 
disease. Nutrients and tonics are indicated. Absorbents, like 
the iodides, mercurials, and ammonium chloride, have been 
recommended, but are valueless. 



HYDATID CYSTS OF THE LIVER. 83 

HYDATID CYSTS OF THE LIVER. 

(Eehinococcus of the Liver.) 

Etiology and Pathology. — Hydatid cysts are formed 
by the embryos of the taenia eehinococcus, a small tape- worm 
inhabiting the intestines of the dog. 

The eggs of the worm are accidentally ingested by man, and 
embryos are liberated in the stomach, whence they may migrate 
to any organ ; the liver however is most commonly affected 
through the portal vein. The fixed embryo soon develops 
into a cyst which is composed of an external laminated layer 
and an internal breeding layer. A connective-tissue layer is 
formed on the outside from irritation. 

The cyst contains a clear non-albuminous fluid which has a 
specific gravity of 1005 to 1007, and which is rich in chlorides. 

Scolices or larvae develop from the breeding layer; they 
are provided with four suckers and a circle of hooklets, and 
produce daughter-cysts within the parent-cyst. When ingested 
by the dog the larvae develop into mature tape-worms. 

Symptoms. — Small cysts excite no symptoms. There is 
often a slowly-developing, irregular enlargement of the liver ; 
if the cyst is superficial, an elastic or fluctuating mass may be 
detected on palpation. 

On percussion a peculiar vibratory sensation (hydatid thrill) 
may be imparted to the hand. Aspiration yields a clear fluid 
containing hooklets and chlorides. 

Fever, pain, and jaundice are usually absent. 

Events. — (1) It may reach a certain size, and then remain 
latent. (2) Trifling injury may convert it into an abscess. 
(3) Rupture of the cyst externally or into neighboring organs 
may result in death or iii recovery. 

Diagnosis. — Slow development, irregular enlargement, 
elastic feel, the results of aspiration, and the absence of pain, 
fever, and jaundice are the diagnostic features. Suppurating 
cysts will be diagnosed abscesses. An upward-growing cyst 
may present the signs of a pleural effusion. 

Prognosis. — Guardedly favorable. 

Treatment. — When large, aspirate. If the fluid re-collects, 
open and drain. 



84 DISEASES OF THE DIGESTIVE SYSTEM. 

ACUTE YELLOW ATROPHY. 

(Malignant Jaundice.) 

Definition. — A rare and grave disease characterized ana- 
tomically by a rapid destruction of the liver tissue, and mani- 
fested by jaundice, hemorrhages, a reduction in the size of the 
liver, and marked cerebral phenomena. 

Etiology. — Female sex, pregnancy, early life, are predis- 
posing factors. 

Alcoholic excesses, emotional excitement, and syphilis have 
been given as exciting causes. 

The rapid course, widespread lesions, and the fact that it 
has occurred endemically suggest an infectious origin. 

Pathology. — From destruction of its substance the liver 
is quite small. The capsule, being too large for the shrunken 
organ, is wrinkled. The surface is yellowish-red and mottled. 

Histology. — Fat drops, molecular debris, fat crystals, and 
crystals of leucin and tyrosin take the place of normal liver- 
cells. The other organs reveal fatty degeneration. 

Symptoms. — (1) The initial symptoms, which are those of 
catarrhal jaundice, are : Malaise, slight fever, coated tongue, 
nausea, vomiting, and jaundice. (2) Nervous symptoms fol- 
low ; these are: Severe headache, delirium, convulsions, and 
coma. Sometimes these symptoms precede the jaundice. (3) 
The urine is scanty, and contains albumin, blood, tube-casts, 
and crystals of leucin and tyrosin. (4) Hemorrhages are com- 
mon, the skin may be covered with ecchymoses, and bleeding 
from the mucous membranes may occur. (5) The area of 
hepatic dulness is diminished, but the area of splenic dulness 
is increased. 

Diagnosis. — The grave cerebral symptoms, reduced hepatic 
dulness, and hemorrhages \vill separate it from catarrhal jaun- 
dice. 

Phosphorus-poisoning. — History, phosphorus in the urine, 
primary enlargement of the liver, and the great severity of 
the initial gastric symptoms. 

Prognosis — Almost invariably fatal. Death results within 
a week after the appearance of cerebral symptoms. 

Treatment. — Palliative. 



DISEASES 

OF 

THE KIDNEYS. 



THE URINE. 

Normal urine is a pale, amber-colored fluid, of acid reaction, 
having a specific gravity of 1015 to 1025, and amounting in 
quantity to about fifty ounces in twenty-four hours. 

Polyuria. — An increased flow of urine. 

Temporary polyuria results from : (1) Excessive ingestion 
of fluids. (2) Diuretics. (3) Suppression of perspiration. (4) 
Crises of certain febrile diseases, and certain neurotic manifes- 
tations, such as excitement, neuralgia, and hysteria. (5) Ab- 
dominal enlargements, as in pregnancy, effusions, and tumors. 
(6) Removal of some temporary obstruction in the urinary 
passages. 

Permanent polyuria results from : (1) Diabetes mellitus. 

(2) Diabetes insipidus. (3) Chronic interstitial nephritis. (4) 
Amyloid kidney. 

The urine is diminished or suppressed (anuria) in the fol- 
lowing conditions: (1) Excessive secretion through other 
channels, as in free perspiration and diarrhoea. (2) In fever. 

(3) Passive renal congestion, from obstructive heart, lung, or 
liver disease. (4) Organic obstruction in the urinary pass- 
ages. (5) In acute and chronic parenchymatous nephritis. 
(6) Nervous causes, as in hysteria, and in the reflex inhibition 
after abdominal injuries or operations. 

Urea. — Urea results from the perfect decomposition of the 
nitrogenous elements of food and tissues. It is perfectly solu- 

(85) 



86 DISEASES OF THE KIDNEYS. 

ble in urine, but the nitrate of urea crystallizes in the form of 
transparent imbricated plates when nitric acid is added to urine 
that has been partially evaporated. 

The amount of urea excreted varies greatly in health. Nor- 
mal urine contains about 2 to 2J per cent, of urea. 

It is increased: (1) After the ingestion of much albuminous 
food. (2) After exertion. (3) In acute inflammatory pro- 
cesses and in fevers. (4) In diabetes. 

It is diminished: (1) In nephritis. (2) In organic diseases 
of the liver. (3) In wasting diseases and in ansemia. (4) In 
starvation. 

Fowler 7 s Hypochlorite Test for Urea, — Add to 1 volume of 
the urine 7 volumes of Labarraque's solution of chlorinated 
soda. Shake the jar containing the mixture occasionally, and 
stand it aside for two hours, when the urea will have been 
decomposed. Now take the specific gravitv of the quiescent 
fluid. 

2d. Ascertain the specific gravity of the mixture of urine and 
Labarraque's solution before decomposition. To do this, mul- 
tiply the specific gravity of the pure Labarraque's solution by 
7, add this to the specific gravity of the pure urine, and divide 
by 8. The result is the specific gravity of the mixed fluid. 
From this subtract the specific gravity of the quiescent mix- 
ture after decomposition of the urea, multiply the difference 
by .77, and the result is the percentage of urea. — Tyson. 

Lithuria. — Uric acid or urates in the urine. These sub- 
stances are formed by the imperfect metamorphosis of tissues 
and nitrogenous food. When they are in excess the urine is 
heavy, dark in color, and on cooling throws down a brick-red 
deposit, termed " lateritious" (later, a brick). 

Microscopically, uric acid appears as reddish -yellow rhombic 
prisms or lozenge-shaped crystals. 

Amorphous urates appear as fine, dark, and opaque granules. 

Crystalline urates appear as needles, dumb-bells, or as 
globular masses from which sharp spines project. 

Murexide Test for Uric Acid and its Salts. — Evaporate a little 
urine in a porcelain dish, add a drop or two of strong nitric 
acid, and heat again to dryness. Cool, and add a drop of 



THE TRINE. 



87 



liquor ammonite, and the beautiful purple color of murexide 
is developed. 

Fig. 3. 




Uric acid and uric acid salts. 



Urates, — The urates are present in small quantity in normal 
urine. They may become perceptible or transiently increased : 

(1) In urine exposed to a cold atmosphere. (2) In urine made 
scanty by free perspiration or diarrhoea. (3) When the acidity 
of the urine is temporarily increased. (4) After the excessive 
indulgence in nitrogenous food. 

The urates are increased pathologically in many diseases 
which directly or indirectly interfere with tissue or food metab- 
olism, notably in : (1) Lithsemia or the gouty diathesis. 

(2) Fever. (3) Extreme anaemia, (4) Diseases of the lungs — 
from interference with oxidation. 

Leucin and Tyrosin These substances are found in the urine 

in certain specific fevers, in grave anaemia, and especially in 
fatty degeneration of the liver resulting either from phos- 
phorus-poisoning or acute yellow atrophy. 

They may be detected by evaporating a few drops of the 
urine on a glass slide. Leucin appears in the form of small, 
round, glistening spheres, resembling fat drops, but unlike the 
latter they are insoluble in ether. Tyrosin appears in the 
form of intersecting tufts of fine acicular crystals. 



88 



DISEASES OF THE KIDNEYS. 
Fig. 4. 




a. Tyrosin crystals, b. Leucin crystals. 

Phosphates, — There are two forms, amorphous and crystal- 
line. 

Amorphous earthy phosphates are found in alkaline urine, 
and are precipitated by adding a few drops of liquor ammonia? 
to the urine. 

( 'rystaMized phosphate of lime appears as stellar or rod- 
shaped crystals which are soluble in acetic acid. 

Fig. 5. 




Triple phosphate. 



The amiiionio-mac/nesiaii phosj)hate, or triple phosphate, ap- 
pears in decomposing urine as transparent coffin-shaped prisms. 
They may resemble crystals of oxalate of lime, but, unlike 
the latter, are freely soluble in acetic acid. 



THE URINE. 



89 



The presence of phosphates in the urine is no indication of 
excess, for when normal in amount they are often precipitated 
in urine that is temporarily alkaline. 

The detection of triple phosphates in newly-voided urine 
indicates decomposition in the bladder, a condition resulting 
from vesical catarrh. 

Phosphates are often increased in nervous dyspepsia, melan- 
cholia, and neurasthenia. 

Chlorides. — The quantity of these salts is increased : (1) 
After exertion. (2) During the absorption of mechanical or 
inflammatory effusions. (3) In intermittent fever, from the 
destruction of corpuscles. 

The quantity is decreased : (1) In most febrile diseases. 
(2) In nephritis. (3) In many wasting diseases. (4) Espe- 
cially in pneumonia. 

Test — We may thus roughly estimate the quantity. Add 
a few drops of strong nitric acid to the urine, remove any 
albumin that may be present, and then add to the clear urine 
a little of a strong solution of nitrate of silver. The abund- 
ance of the white precipitate will indicate the quantity of chlo- 
rides present. 

Fig. 6. 




Oxalate of lime. 



Oxaluria. — Oxalate of lime appears in the urine as dumb- 
bell-shaped crystals, or as minute highly refracting octahedra. 



90 DISEASES OF THE KIDNEYS. 

Many conditions produce them. They are found : (1) After 
eating certain fruits and vegetables, as rhubarb, cauliflower, 
and pears. (2) In certain diseases, notably nervous dyspepsia, 
hypochondria, melancholia, diabetes, and wasting diseases. 

In these cases the oxalates result from the imperfect metab- 
olism of organic substances. 

Urobilimiria. — Urobilin is a coloring principle derived from 
the blood. When present in the urine in large amount it pro- . 
duces a reddish-brown color ; when deposited in the tissues it 
produces a form of jaundice which has been called urobilin- 
icterus (Jaksch). 

Urobilimiria occurs: (1) Occasionally in health. (2) In 
pyrexia. (3) After the absorption of hemorrhagic effusions. 
(4) In liver disease. (5) In grave anaemia. 

G-lucosuria or Glycosuria.— Glucose in the urine. 

Its Causes. — (1) Normal urine contains a trace. (2) Diabetes 
mellitus. (3) Certain diseases, as gout, chorea, tetanus, and 
functional nervous affections. (4) Ingestion of much sacchar- 
ine or amylaceous material. (5) Pregnancy. (6) Toxic sub- 
stances in the blood, as the nitrites and carbon monoxide. 

Qualitative Tests for Glucose. — The copper tests are commonly 
employed, and depend on the power which glucose possesses of 
converting blue oxide of copper into the orange-yellow sub- 
oxide. 

Trommels Test. — Add to the suspected urine half its volume 
of liquor potassae, and if any precipitate falls filter the solution ; 
then add one or two drops of a weak solution (1-30) of sulphate 
of copper, and heat the resulting mixture. If sugar is present, 
a dense yellow or red precipitate falls. 

Simple decolorization of the fluid is no proof of sugar. 

Fehling's Test. — The solution should be freshly prepared 
when required, by adding in equal proportions the following 
solutions : — 

First solution : Dissolve 34.64 grams of cupric sulphate in 
distilled water, and dilute up to a litre. 

Second solution : Dissolve 173 grams of Eochelle salt in 
350 c. c. of distilled water, and heat to boiling ; on cooling, 
add 600 c. c. of a solution of caustic soda (sp. gr. 1.12) that 



THE URINE. 91 

has been previously boiled, and make up to a litre with dis- 
tilled water. 

To about ten minims of each solution in a test-tube add 
about a fluid drachm of distilled water, and boil for a few sec- 
onds ; if the solution remains clear, add the suspected urine 
drop by drop, and occasionally heat the tube. If sugar is 
abundant, a yellowish-red deposit will be produced. If no 
precipitate falls, continue the addition of the urine until an 
equal volume has been added, and allow to cool ; then if no 
precipitate falls, sugar is absent. 

Pavy's Solution may be used instead of Fehling's solution. 
It contains 320 grains of sulphate of copper, 640 grains of 
neutral tartrate of potassium, 1286 grains of caustic potash, 
and 20 fluidounces of distilled water. As other organic sub- 
stances and urochloralic acid (after administration of chloral) 
yield precipitates of the suboxide of copper, Bottger's test or 
the fermentation test may be employed as guard tests. 

Bottger's Test. — Add to a couple of drachms of suspected 
urine which is free from albumin an equal volume of liquor 
potassse and a few grains of subnitrate of bismuth, and boil ; 
if sugar is present, it will reduce the salt of bismuth to black 
metallic bismuth. Substances containing sulphur, like albu- 
min, yield a similar black precipitate. 

The Fermentation Test. — Fill a four-ounce bottle three parts 
full of urine, and add a fluid drachm of ordinary yeast, or a 
small portion of compressed yeast, lightly cork, and subject to 
a temperature of 70° to 80° Fahr. for ten or twelve hours. 
If sugar is present, fermentation results with the evolution of 
carbon dioxide, and the specific gravity of the urine falls. 

Quantitative Tests. — Fermentation test : Employ two bottles 
of urine, and to the one add the yeast ; at the end of twenty- 
four hours take the specific gravity of each specimen. Every 
degree lost in the fermented urine indicates a grain of sugar 
to the fluidounce. 

Fehling's Test. — To one cubic centimetre of Fehling's solu- 
tion add four cubic centimetres of distilled water, and boil ; 
if the solution still remains clear, add T ^ c. c. of the urine 
from a graduated pipette, and gently heat. Continue the ad- 
dition of the urine, little by little, until all blue color has dis- 



92 DISEASES OF THE KIDNEYS. 

appeared. If one cubic centimetre of urine has been added, it 
will have contained half of one per cent, of sugar. If two 
c. c. are used, it will have contained one-quarter per cent. If 
but a half of a cubic centimetre is used, it will have contained 
one per cent. 

If the specific gravity indicates that the amount of sugar is 
great, dilute the urine with a definite amount of water, and 
estimate accordingly (Tyson). 

Albuminuria. — Albumin in the urine. 

Its Causes. — (1) All forms of nephritis. (2) Congestion of 
the kidney, as the result of chronic heart, lung, or liver dis- 
ease. (3) Pregnancy. (4) Cyclical. The urine may be albu- 
minous at certain times, as after meals, heavy exercise, bathing, 
or on rising in the morning. (5) Accidental. From the admix- 
ture of albuminous substances with the urine, as pus, semen, 
and blood. (6) Certain nervous diseases, as epilepsy, tetanus, 
and injury to the brain. (7) Extreme anaemia. (8) Ingestion 
of large amounts of albuminous food. 

Tests for Albumin. Heller's Test. — Pour a small quantity of 
colorless nitric acid in a test-tube, and allow an equal quantity 
of filtered urine to trickle from a pipette down the sides of the 
tube and to come in contact with the acid. If albumin is 
present, a sharply-defined white ring is formed at the line of 
junction. 

Turpentine, copaiba, and other oleoresins eliminated in the 
urine yield similar rings, but the latter are redissolved on the 
addition of alcohol. 

Uric acid produces an undefined pink ring, but it is not 
exactly at the line of contact, and is redissolved on the ap- 
plication of heat. 

Johnson's Test. — Fill a six-inch test-tube two-thirds full of 
filtered urine, and allow a couple of drachms of a clear satu- 
rated solution of picric acid to flow down the side of the tube 
and to mix with the urine. Turbidity indicates the presence 
of albumin, and it increases on gently heating the tube near its 
mouth. Certain substances in the urine, like the alkaloids, 
produce a similar turbidity, but this disappears on the appli- 
cation of heat. 



THE URINE. 93 

Roberts's Nitric Magnesian Test. — Very delicate and reliable. 
The test-fluid is made by adding one volume of strong nitric 
acid to five volumes of a saturated solution of sulphate of 
magnesium, and is employed in the same manner as nitric acid 
in Heller's test. 

Acetonuria. — Acetone results from the metamorphosis of 
albumin, and is found in the urine in many conditions, 
notably : (1) A trace in normal urine. (2) In Cancer. (3) 
Febrile diseases. (4) Psychoses. (5) It may arise as a primary 
condition. (Von Jaksch.) (6) In diabetes it is often abund- 
ant. It is not responsible for diabetic coma (Acetonemia). 

Xitro-prussicle Test for Acetone. — To an ounce of urine acid a 
couple of drachms of a solution of nitro-prusside of sodium (5 
grains to the ounce), and a few drops of strong aqua ammonise, 
and if acetone is present a rose-violet color develops on standing. 

Diaceturia and Oxybutyria — Diacetic acid and oxybutyria 
acid are never found in normal urine, but are found associated 
with acetone in certain fevers, and especially in diabetes. 
Their decomposition yields acetone, and they are probably the 
cause of diabetic coma. 

Test for Diacetic Acid. — Boil the urine and add a solution 
of ferric chloride. If diacetic acid is present, a Burgundy-red 
color develops. 

Hematuria. — Blood in the urine. 

The chief causal conditions are: (1) Vicarious menstrua- 
tion. (2) Traumatism applied to any part of the genito- 
urinary tract. (3) General blood dyscrasia, as in the specific 
fevers, purpura, malaria, scurvy, etc. (4) Congestion of the 
kidney from chronic heart, lung, or liver disease. (5) Acute 
inflammation of any part of the genito-urinary tract. (6) Stone 
in the genito-urinary tract. (7) Varicose veins at the neck of 
the bladder. (8) It may occur paroxysmally without obvious 
cause. (8) Parasites in the genito-urinary tract, as the Filaria 
sanguinis hominis, and the Distoma haematobium. 

Diagnosis. — By the color of the urine and by microscopic 
and spectroscopic examination. 

Heller's Test. — Boil the urine with a solution of caustic 
potash, and phosphates are precipitated which assume a red 
color from the freed hsematin. 



94 DISEASES OF THE KIDNEYS. 

Source of the Hemorrhage. Urethra. — The urine first passed 
is bloody, and the other symptoms point to the urethra. 

Bladder. — Bleeding often at the end of micturition, and 
other symptoms, point to the bladder. 

Kidney. — Blood intimately mixed. There may be blood- 
casts or clots, and the other symptoms point to the kidneys. 

Haemoglobimiria. — Blood-pigment in the urine. 

The chief causal conditions are: (1) Blood disintegration 
from the specific fevers, scurvy, purpura, malaria, etc. (2) 
Absorption of internal hemorrhagic effusions. (3) It follows 
transfusion of blood. (4) Paroxysmally, without obvious cause. 

Indicanuria, — Indican is a colorless compound resulting 
from the decomposition of albuminous substances in the small 
intestine, and by oxidation is converted into indigo. 

It occurs (1) Occasionally in health. (2) From undue reten- 
tion of material in the small intestine, as in peritonitis, intes- 
tinal obstruction, and obstinate constipation. (3) In wasting 
diseases. 

Test for Indican. — Mix equal volumes of urine and fresh 
nitro-hydrochlorie acid, and add, drop by drop, a fresh con- 
centrated solution of chloride of lime. Indican is indicated by 
the appearance of an indigo-blue color. 

Bile. — Bile- pigment is found in the urine in all forms of 
jaundice. 

Bile-acids in the urine indicate hepatogenous jaundice, but 
their absence in jaundice is no proof that the latter is hsemoto- 
genous in origin. 

Gmellbis Test for Bile-pigment. — Allow a few drops of urine 
and a few drops of fuming nitric acid to come together on a 
white plate. If bile is present, there will be an iridescent play 
of colors — green, blue, violet, and red — at the line of contact. 

Pettenkoffer' 's Test for Bile-acids. — Add a few grains of cane- 
sugar and a drop of sulphuric acid to the suspected urine in a 
test-tube ; heat gently, and if bile-acids are present a violet- 
red color is produced. 

Ciiyluria. — Chyle in the urine. It produces a milky tur- 
bidity which gradually rises to the top of the urine in the form 
of pellicles of finely-divided fat. Its chief causes are: (1) 
Injury to the lymphatic ducts. (2) Pregnancy. (3) Obstruc- 



RENAE HYPEREMIA. 95 

tion of the lymphatic ducts by the Filaria sanguinis hominis, 
a thread-worm most commonly met with in the tropics. 

Pyuria. — Pus in the urine. It results (1) from suppura- 
tive inflammation of any part of the genito-urinary tract, and 
(2) from the rupture of abscesses into the tract. 

It appears as a dull, greenish-yellow precipitate which is 
converted into a clear gelatinous mass by the addition of liquor 
potassae. It can always be detected by the microscope. 

Source. — AVhen pus is from the kidney it is intimately mixed 
with the urine, the latter has an acid or neutral reaction, and 
the associated symptoms point to the kidneys. 

AYhen the pus is from the bladder it is not so intimately 
mixed with the urine ; the latter is usually alkaline in reaction, 
and the associated symptoms point to the bladder. 

KENAIi HYPEREMIA. 

Varieties. — (1) Active hyperamia, and (2) passive hy- 
peremia. 

Active Hyperemia. 

(Acute Congestion.) 

Causes. — (1) Exposure to cold when the body is over- 
heated. (2) Eruptive fevers. (3) Poisons, as the stimulating 
diuretics. (4) Pregnancy. 

The same cause aggravated would produce acute nephritis. 

Pathology. — The kidney is swollen, of a deep red color, 
and bleeds freely on section. Microscopic examination reveals 
cloudy swelling of the renal epithelium. 

Symptoms. — Pain over the loins. The urine is dark, 
scanty, of high specific gravity, and may contain a trace of 
albumin, a few hyaline casts, and some free blood. 

Prognosis. — If the cause can be removed, the prognosis is 
favorable. 

Treatment. — Absolute rest. Wet cups or warm fomenta- 
tions over the loins. Liberal use of water. Saline laxatives. 
Encourage sweating by the vapor bath or small doses of pilo- 
carpin. The infusion of digitalis may be used to increase the 
quantity of urine. 



96 DISEASES OF THE KIDNEYS. 

Passive Hyperemia. 

(Chronic Congestion.) 

Etiology. — (1) Causes which obstruct the genera! circula- 
tion, as chronic heart, lung, and liver disease. (2) Pressure 
of tumors on the renal veins. (3) Rarely thrombosis of the 
renal veins. 

Pathology. — The kidney is swollen and of a bluish-red 
color, and later becomes hard from an overgrowth of con- 
nective tissue (cyanotic induration). In advanced cases the 
renal epithelium is fatty. 

Symptoms. — Sensation of weight over the loins. The urine 
is usually diminished, but is rarely increased in quantity. 
Free blood, a little albumin, and occasionally a few narrow 
hyaline casts are found. 

Diagnosis. — The comparative absence of albumin and 
casts, the absence of dropsy and ursemic symptoms, and the 
presence of urea in normal amount will separate congestion 
from nephritis. 

Prognosis. — Depends on the cause. 

Treatment. — Rest. Light diet. Dry cups to the loins. 
The use of diuretics when the urine is scanty. The following 
tonic diuretic pill may be of service : — 

I£ Quininse sulph., gr. xxx ; 

Pulv. digitalis, gr. xxx ; 

Pulv. scillae, gr. xxx ; 

Ext. nucis vomicae, gr, v ; 

Pulv. ferri carb., gr. xxx. — M (Pepper.) 
Div. in pil. No. xxx. 
Sig. — One pill every three hours. 

UILEMIA. 

Definition. — The name applied to a group of symptoms 
resulting from the retention of toxic materials in the blood 
which should have been eliminated by the kidneys. 

Symptoms. — It may develop slowly or abruptly, and may 
manifest any of the following phenomena: Headache, ver- 
tigo, delirium, epileptiform convulsions, coma, sudden blind- 



ACUTE NEPHRITIS. 97 

ness (unassociated with any retinal change), and transient 
paralysis from congestion or oedema of the brain or cord. 

Pulmonary Symptoms. — Dyspnoea, (ursemic asthma), Cheyne- 
Stokes breathing. 

Abdominal Symptoms. — Hiccough, obstinate vomiting, and 
purging. 

General Symptoms. — The skin is dry; the breath has a 
urinous odor; the urine is scanty and deficient in urea. The 
pulse is slow and full, and the temperature subnormal ; but 
daring convulsions the temperature may rise and the pulse 
become rapid and feeble. 

Diagnosis. — The various manifestations may be recognized 
as uraemic by the history, the temperature, the odor of the 
breath, the high arterial tension, the accentuated second sound 
of the heart, the presence of casts and albumin in the urine, 
and by the absence of any other cause. 

Prognosis. — Grave, but always guarded, for recovery is 
possible after the most serious manifestations. 

Treatment. — Encourage sweating by the use of hot air, 
or vapor baths. Encourage catharsis by the use of croton oil 
(one drop in a drachm of olive oil), elaterium (gr. §), or a 
concentrated solution of Epsom salts. 

Relieve renal engorgement by digitalis poultices, or dry 
or wet cups to the loins. When the patient is robust, and 
the pulse is strong, venesection will be of paramount impor- 
tance. If the pulse is very weak, alcohol, strychnia, digitalis, 
and ammonia may be required hypodermically. 

In convulsive seizures, in addition to the above treatment, 
chloral (gr. xxx-xl) may be given by the rectum, and nitrite 
of amyl or chloroform by inhalation. 

ACUTE NEPHRITIS. 

(Acute Bright' s Disease, Acute Tubular Nephritis, Acute Desqua- 
mative Nephritis, Acute Parenchymatous Nephritis, Acute 
Catarrhal Nephritis.) 

Definition. — An acute inflammatory process involving 
more or less the whole kidney, but especially affecting the 
epithelium of the tubules and glomeruli. 

7 



98 DISEASES OF THE KIDNEYS. 

Etiology. — (1) Exposure to cold and wet. (2) The spe- 
cific fevers, especially scarlet fever. (3) Poisons which are 
eliminated through the kidneys, as cantharides, turpentine, etc. 
(4) Pregnancy. 

Pathology. — The kidney is swollen and the capsule non- 
adherent. At first the organ is bright red in color ; it soon, 
however, becomes pale and mottled in appearance, although 
the Malpighian tufts still retain their deep red tint. 

Histology. — The epithelium of the tubules and glomeruli 
is the seat of cloudy swelling and, later, of fatty degeneration. 
Desquamated epithelium, blood-corpuscles, and an albuminous 
exudate block up the tubules. The capillaries are dilated, 
their walls degenerated, and bloody extravasations are not in- 
frequently seen. The interstitial tissue is more or less infil- 
trated with leucocytes. 

Symptoms. — Moderate fever and its associated symptoms ; 
dull lumbar pain ; vomiting and dropsy, beginning in the face 
and becoming general ; rapid anaemia. Ursernic symptoms 
may develop at any time. 

The Urine. — Scanty and at times suppressed. It is smoky 
in appearance, of high specific gravity, rich in albumin, and 
throws a heavy sediment, which contains hyaline, blood, and 
epithelial casts, and free blood and epithelial cells. 

Diagnosis. — As the general symptoms are often slight, the 
diagnosis must rest on the examination of the urine. The 
history, and the absence in the urine of wide, highly fatty 
casts, will serve to distinguish acute nejihritis from an acute 
exacerbation of chronic parenchymatous nephritis. 

Prognosis. — Guardedly favorable. It may kill by ex- 
haustion, uraemia, or dropsy. 

Treatment. — Absolute rest in bed until albumin has dis- 
appeared from the urine. Milk is the best food ; but butter- 
milk, gruels, and light broths are admissible. The free use of 
water should be encouraged. Dry or wet cups, or hot fomen- 
tations should be applied to the loins. To secure vicarious 
action of the skin vapor baths or small doses of pilocarpin 
(gr. J to -fa) may be employed. Concentrated saline draughts, 
made of Rochelle or Epsom salts, may be given to secure 
watery discharges from the bowels. Compound jalap powder 



CHRONIC PARENCHYMATOUS NEPHRITIS. 99 

(gr. xx), or elaterium (gr. J) may be substituted for the saline. 
Stimulating diuretics should be avoided, and diuresis encour- 
aged by alkaliue waters and infusion of digitalis. Uraemia 
will call for its appropriate treatment. 

Severe cases in pregnancy will require the induction of 
abortion or premature labor. 

Marked effusions into the serous cavities will sometimes 
demand aspiration. Convalescence should be protracted, and 
the resulting anaemia will call for some preparation of iron, 
such as Basham's mixture. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

(Chronic Catarrhal Nephritis, Large White Kidney.) 

Etiology. — (1) It may result from acute nephritis. (2) It 
may be chronic from the beginning. Male sex, adult life, 
frequent exposure to cold and wet, alcoholism, and syphilis 
are predisposing factors. 

Pathology. — In the first stage the kidney is large and 
pale-yellow in color ; the pallor depends on anaemia and fatty 
degeneration ; the tubes are filled with fatty epithelium and 
casts ; there is always some overgrowth of the interstitial con- 
nective tissue. 

In the second stage the organ is small, pale in color, its sur- 
face rough, and its capsule somewhat adherent. The reduced 
size depends on destruction of the renal epithelium and the 
contraction of the overgrown connective tissue. 

Symptoms. — As it usually begins as a chronic affection, 
the following symptoms slowly manifest themselves : Pro- 
gressive loss of flesh and strength ; marked anaemia ; gastro- 
intestinal disturbances ; dropsy, often first noted in the face 
on rising in the morning ; increased arterial tension ; some 
hypertrophy of the left ventricle, so that the second sound at 
the aortic cartilage is accentuated. Ursemic symptoms may 
develop at any time. 

The Urine. — Usually diminished, although it is frequently 
normal in color and in appearance. It is highly albuminous, 
and throws down an abundant sediment, which contains hya- 
line, fatty, and granular casts, and fatty epithelial cells. 



100 DISEASES OF THE KIDNEYS. 

Complications. — These are Diimerous and often suggest 
the diagnosis. The most common are uraemia, extensive 
dropsy into the tissues or serous cavities, latent inflammations 
of the serous membranes, valvular heart disease, albuminuric 
retinitis, and acute exacerbations. 

Prognosis. — Unfavorable. In the early stages recovery 
sometimes results. The duration is from a few months to 
several years. 

Treatment. — The treatment is largely dietetic and 
hygienic. Residence in a dry, warm, and equable climate 
may prolong life or effect a cure. Rest is an essential element 
in the treatment. The underclothing should be woollen or 
silk. The diet should be non -nitrogenous, and in severe cases 
an absolute milk diet may be of extreme value. The bowels 
should be kept active by natural mineral waters or saline 
laxatives. When the urine is scanty, digitalis or caffeine may 
prove efficient diuretics. Basham's mixture may be employed 
as a chalybeate and a diuretic. 

In excessive dropsy promote catharsis by Epsom salts in 
concentrated solution, or by compound jalap powder; and 
promote diaphoresis by the hot-air bath, or by pilocarpin. 

The following combination is often very efficient in trouble- 
some dropsy : — 

]£ Mass. hydrarg., gr. xx ; 

Pulv. digitalis, gr. xx ; 

Pulv. scillse, gr. xx.— M. (Niemeyer.) 
Ft. in pil. No. xx. 
Sig.— One pill thrice daily. 

Acute exacerbations should be treated as primary atacks of 
acute nephritis. 

CHRONIC INTERSTITIAL NEPHRITIS. 

(Red Granular Kidney, Contracted Kidney, Gouty Kidney.) 

Definition. — A chronic inflammatory condition of the 
kidney characterized by a reduction in its size, due to an over- 
growth and subsequent contraction of its connective-tissue 
elements, and invariably associated with general arterial scle- 
rosis and cardiac hypertrophy. 



CHRONIC INTERSTITIAL NEPHRITIS. 101 

Etiology. — It may be secondary to parenchymatous 
nephritis, or result from the passive congestion of chronic 
heart disease ; but generally it arises as a primary condition, 
and results from the causes which predispose to sclerosis in 
other organs, viz., middle life, male sex, syphilis, the gouty 
diathesis, chronic alcoholism, and chronic mineral poisoning, 
as from lead. 

Pathology. — The kidneys are small, and red in color. 
The surface is granular, and the capsule adherent. The or- 
gan is firm, cuts with difficulty, and on section often reveals 
small cysts or calcareous deposits. The cortical substance is 
greatly reduced in thickness. Microscopic examination shows 
an overgrowth of connective tissue which has contracted, nar- 
rowed the lumen of the tubules, and interfered with the 
nutrition of the epithelium, and as a result the latter may 
show fatty degeneration with desquamation. The arteries 
throughout the body reveal fatty degeneration of the media 
and an overgrowth of connective tissue in the intima (arterio- 
sclerosis), and from the resistance thus offered hypertrophy of 
the heart has resulted. 

Symptoms. — A slow loss of flesh and strength with pro- 
gressive anaemia. Gastric disturbances are very common. 
The arteries are rigid, and the pulse is of high tension, so that 
the second sound of the heart is accentuated at the aortic carti- 
lage. 

Palpitation of the heart is often noted. Dyspnoea is a 
prominent symptom, and may result from heart- weakness, 
uraemia, or oedema of the lungs. Headache, vertigo, and 
insomnia often result from disturbed circulation, and dimness 
of vision from albuminuric retinitis. 

Dropsy is often absent, or is slight and appears late in the 
disease. 

The urine : Increased in quantity, pale in color, and of low 
specific gravity (1010-1005), and contains but a trace of albu- 
min and a few narrow hyaline casts. 

Complications. — Albuminuric retinitis, valvular heart 
disease, apoplexy resulting from the weakened arteries and 
large heart, uraemia, latent inflammations of serous mem- 
branes, pneumonia, and bronchitis. 



102 DISEASES OF THE KIDNEYS. 

Diagnosis. — The arterial changes, casts in the urine, 
uraemic symptoms, and the absence of poikiloey tosis will serve 
to distinguish chronic nephritis from pernicious ancemia. 

Chronic parenchymatous nephritis usually occurs earlier in 
life, lacks much arterial change, produces considerable dropsy , 
and urine that is rich in albumin and tube-casts. 

Pbognosis. — It is incurable, but may last many years, and 
under favorable conditions comparative comfort may be ob- 
tained. 

Treatment. — The dietetic and hygienic treatment is the 
same as in chronic parenchymatous nephritis. Frequent bath- 
ing with friction of the skin should be encouraged, and the 
bowels kept regular by alkaline waters. 

Absorbents, like the bichloride of mercury and iodide of 
potassium, are of no value. If the stomach will bear it, iron 
will be of service. Digitalis, caffeine, and strychnia will be 
very useful when the heart weakens. Nitroglycerin, in one 
minim doses, gradually increased, has been recommended for 
the high arterial tension. 

AMYLOID KIDNEY. 

(Waxy Kidney, Lardaceous Kidney.) 

Etiology. — (1) Prolonged suppuration, particularly in 
bone disease. (2) Tuberculosis. (3) Syphilis. (4) Malarial 
cachexia. 

Pathology. — The kidney is large and pale, and on sec- 
tion presents a " bacon-like" appearance. 

Lugol's solution of iodine strikes a mahogany-red color 
with the amyloid material. 

On microscopic examination, the walls of the bloodvessel.-, 
particularly those of the Malpighian tufts, are found thickened, 
and infiltrated with a homogeneous wax-like material, which 
turns red when treated with a weak solution of gentian-violet. 
.Parenchymatous and interstitial changes are always noted, 
other organs, especially the liver and spleen, are similarly 
affected. 

Symptoms. — Loss of flesh and strength, with great pallor 
and moderate dropsy. Ursemic symptoms are uncommon. 



RENAL CALCULUS. 103 

The liver and spleen are often much enlarged from the same 
degeneration. 

The Urine. — Usually increased in amount, pale in color, and 
contains considerable albumin and wide hyaline and granular 
casts. 

Diagnosis. — The history, the enlarged liver and spleen, 
and the increased amount of urine containing considerable 
albumin suggest the diagnosis. 

Prognosis. — When not advanced, and the cause can be 
removed, the disease may be arrested. As a rule, the prog- 
nosis is decidedly unfavorable. 

Treatment. — The primary disease will claim attention. 
In bone disease, surgical interference may be requisite. In 
syphilis, iodide of potassium and mercurials will be indicated. 
In malarial cachexia, iron, quinine, and arsenic should be em- 
ployed. Tuberculosis will call for its appropriate remedies. 

The treatment of the morbid condition is hygienic and 
dietetic. Alterative tonics, like the iodide- of iron, may prove 
beneficial in some cases. 



RENAL CALCULUS. 

(Nephrolithiasis, Renal Gravel.) 

Definition. — A precipitated urinary concretion found in 
the kidney. 

Etiology. — (1) Male sex. (2) Heredity. (3) Mai-assimi- 
lation. (4) Inflammation of the pelvis of the kidney. Doubt- 
less mucus or desquamated epithelium forms the nucleus upon 
which the stone is built. 

Varieties. — (1) Uric acid. This may be passed as sand, 
or form large reddish-brown stones (2) Oxalate of lime. 
This forms a very hard, dark, and uneven stone (mulberry 
calculus). (3) Phosphates. These are composed of phosphate 
of lime, and ammonio-magnesium phosphate, and are soft, 
mortar-like in appearance, and are often deposited on other 
calculi. (4) Xanthine and cystine are rare concretions. 

Events. — (1) A stone may remain latent indefinitely. {'2) It 
may pass out, with or without the symptoms of colic. (3) It 



104 DISEASES OF THE KIDNEYS. 

excites pyelitis, and sometimes abscess of the kidney. (4) It 
may obstruct the ureter and produce hydro-nephrosis or pyo- 
nephrosis. (5) It may excite perinephritis, and may perforate 
in other organs. 

Symptoms of Bexal Colic. — Sudden onset, with sharp 
pain, starting in the back and radiating down the ureter, the 
penis, testicle, or thigh. There may be retraction of the testi- 
cle on the affected side. 

The symptoms of intense pain are often present, viz : 
pallor, cold sweats, w T eak pulse, and reflex vomiting. 

The urine subsequently passed may contain the stone ; or, 
as a result of irritation, pus, blood and desquamated pelvic 
epithelium. An attack may last from a few moments to 
several hours. 

Diagnosis. Biliary and Renal Colic. — In the former the 
pain runs from the right hypochondriac region to the right 
shoulder; there is often jaundice, and the urine is negative, 
while the stools may contain the stone. 

Prognosis. — In view of the complications the prognosis 
must be guarded. 

Treatment. The Attach. — Morphine and atropine should 
be employed hypodermically, and warm poultices applied to 
the loins. The free use of water should be encouraged. In 
severe cases chloroform or ether may be inhaled in sufficient 
quantity to obtund the sensibility of the patient. 

The Interval. — When symptoms persist, regulate the diet, 
and put the patient under good hygienic conditions. When 
the reaction of the urine indicates an acid stone, the salts of 
lithium or the vegetable salts of potash may be employed in 
large doses, over long periods. A drachm of the citrate of 
potassium or five to ten grains of the carbonate of lithium 
may be given, well diluted, several times a day. The natural 
mineral waters are of some value. The Buffalo lithia water 
may be employed for this purpose, and its palatableness and 
efficiency may be increased by the addition of a teaspoonfnl 
of some effervescing preparation of lithium to each potation. 

When an alkaline stone is indicated, benzoic acid or boric 
acid mav be employed in a similar manner. 

In severe and persistent cases the stone may be excised 



PYELITIS. 105 

(nephrolithotomy) ; and if the operation should reveal a 
badlv-damaged kidney, its removal (nephrectomy) would be 
indicated. 

PYELITIS. 

(Pyelonephritis, Pyonephrosis.) 

Definition. — Inflammation of the pelvis of the kidney. 

Etiology. — (1) It may result from stone in the pelvis of 
the kidney (calculous pyelitis). (2) It may be secondary to 
urethritis or cystitis extending upwards through the ureters. 
(3) It may follow pregnancy or the specific fevers. (4) Morbid 
growths, such as tubercle or cancer. (5) Toxic doses of the 
stimulating diuretics (copaiba, cantharides, etc.). (6) It is 
rarely idiopathic from exposure to cold and wet. 

Pathology. — The mucous membrane is swollen, injected, 
and covered with a tenacious secretion composed of mucus, 
pus, and desquamated epithelium. Severe cases may lead to 
dilatation of the pelvis, B right's disease, or suppurative 
nephritis. 

Symptoms. — Moderate fever and its associated phenomena. 
In suppurative nephritis the fever may be irregular and asso- 
ciated with hectic or typhoid symptoms. There is pain and 
sometimes tenderness over the kidneys. The urine is turbid, 
acid in reaction, and on standing throws down a sediment con- 
taining considerable mucus, pus-corpuscles, pelvic epithelium, 
and blood-corpuscles. The pus and blood render the urine 
slightly albuminous. 

Diagnosis. — The absence of much albumin, of tube-casts, 
and dropsy exclude nephritis. 

Cystitis may be excluded by the absence of lumbar pains 
and of acid urine, and by the presence of frequent and painful 
micturition and alkaline urine containing vesical epithelium. 

Perinephritic abscess is also associated with lumbar pain 
and hectic fever ; but in addition there is often oedema over 
the lumbar region, and the urine may be normal. 

Sharp pain over the kidney, increased by jarring movements, 
and reflected down the ureters, and the presence of much blood 
in the urine point to calculous pyelitis. 



106 DISEASES OF THE KIDNEYS. 

Tuberculous pyelitis may be recognized by the history, by 
the presence of tubercle in other organs, and by tubercle bacilli 
in the urine. 

Pyelitis secondary to cystitis is recognized by the history. 

Prognosis. — Depends on the cause. Mild forms resulting 
from pregnancy, specific fevers, or exposure to cold, usually 
recover in a few weeks. The tuberculous and suppurative 
varieties are unfavorable. 

Treatment. — Depends on the cause. Calculous pyelitis 
will require the treatment indicated for renal calculus. In 
simple pyelitis keep the patient at rest, restrict the diet to light 
food, preferably to milk, apply warm poultices locally, use 
alkaline diluents and some sedative mixture, as the following : — 

$. Potass, bromid., 

Sodii bicarb., aa gr. clx ; 
Ext. belladonna?, gr. iv; 
Ext. buchu, 3j ; 

Syr. sarsp. comp., q. s. ad f^iv.— M. (Pepper.) 
Sig. — Tablespoonful three times a day. 

In pyelitis following cystitis, treat the latter locally, and 
use stimulating diuretics, like eucalyptus, sandalwood, and 
copaiba. 

HYDRONEPHROSIS. 

Definition. — Dilatation of the pelvis of the kidney, with 
the accumulation of a watery fluid, resulting from obstruction. 

Etiology. — (1) Congenital stricture of the ureter. (2) Im- 
paction of a calculus in the ureter. (3) Abdominal tumors 
compressing the ureter. (4) Tumors growing within the 
urinary passages. (5) An inflammatory stricture of the ureter 
or urethra. 

Pathology. — The pelvis reveals all grades of distention. 
In extreme cases it may contain several quarts of fluid, which 
is at first urinous, but later thin and watery. There is more 
or less atrophy of the renal tissue. 

Symptoms. — Slight distention yields no symptoms. In 
other cases a tumor slowly develops in the region of the 
affected kidney. On palpation it is elastic, and perhaps 



FLOATING KIDNEY. 107 

fluctuating ; on percussion, dull ; and on aspiration it yields a 
clear fluid, which usually contains urea and uric acicl. 

Diagnosis. — This will be based on the history, the exclu- 
sion of other abdominal enlargements, and the chemical 
analysis of the fluid obtained by aspiration. 

Prognosis. — Usually unfavorable. When it is unilateral, 
and the other kidney secretes a normal amount of urine, con- 
taining a normal amount of urea, the prognosis is guardedly 
favorable. 

Treatment. — When the distention is moderate the treat- 
ment is expectant. When the sac is large, aspirate ; and if 
re-accumulation is rapid, establish a renal fistula or remove 
the organ. 

FLOATING KIDNEY. 

(Movable Kidney.) 

Definition.— A distinctly mobile condition of the kidney, 
dependent upon a relaxation of the tissues which surround it. 

Etiology.— (1) Female sex. (2) Middle life. (3) Rapid 
emaciation leading to the absorption of the perinephritic fat. 

(4) A congenital relaxed condition of the perinephritic tissues. 

(5) Muscular exertion. (6) Repeated pregnancies. 
Symptoms. — The right kidney is the one usually affected, 

probably from its relation to the liver, which moves during 
the respiratory acts. The kidney may be found in any part 
of the abdomen, as a movable tumor, reniform in shape, 
somewhat tender to the touch, and rarely imparting the pulsa- 
tion of the renal artery. 

There may be no subjective symptoms, but a sense of un- 
easiness and attacks of neuralgic pain are often noted. At 
times the kidney may become swollen and very tender, pro- 
bably from twisting of the renal vessels inducing engorgement 
of the organ. Emotional disturbances are often excited by 
the condition. 

Diagnosis. — The reniform shape of the tumor, its free 
mobility, its stationary size, the lessened resistance on percus- 
sion over the renal region of the affected side, and the absence 



108 DISEASES OF THE KIDNEYS. 

of cachexia will serve to diagnose a floating kidney from other 
abdominal tumors. 

Treatment. — In many cases, a regulated diet, the avoid- 
ance of undue exertion, and the use of a broad binder applied 
firmly to the abdomen will be the only treatment required. 
When the symptoms persist the kidney may be stitched in 
its normal place (nephrorrhaphy) ; and if this treatment fails 
the offending organ may be removed (nephrectomy). 



DISEASES 

OF 

THE BLOOD 



THE BLOOD. 



In health the blood amounts to about one-thirteenth of the 
body-weight. Normal blood contains approximately 5,000,000 
red corpuscles, and from 5000 to 15,000 white corpuscles, the 
ratio of the latter to the red corpuscles being variously esti- 
mated as 1 to 300 or 1 to 700. 

OLIGOCYTHEMIA. 

Oligocythemia, or a diminution in the number of red corpus- 
cles, occurs in all forms of anaemia, but is especially marked 
in pernicious anaemia, where the number may fall as low as 
400,000 to the cubic millimetre. 

LEUCOCYTOSIS. 

Leucocytosis, or an actual or relative increase in the number 
of white corpuscles, occurs temporarily after eating, after hemor- 
rhage, and permanently in leucaemia. 

POIKILOCYTOSIS. 

Poikilocytosis, or a condition in which the red corpuscles 
are irregular in shape, may occur in any form of severe anae- 
mia, but is especially marked in pernicious anaemia, 

( 109 ) 



110 diseJRses of the blood. 

Fig- 7. 

4 e 




*~^D & * * 







° °— - 



d 

Poikild-, macro-, inicrocytosis (as represented by the letters d. 6, c). a, normal blood- 
corpuscles ; e, product of decomposition of a red blood-corpuscle ; /, nucleated red blood- 
corpuscle (marked antemia). 

3IICROCYTOSIS AND MACROCYTOSIS. 

Mierocytosis and rnacrocytosis are conditions in which the 
red corpuscles are respectively diminished and increased in 
size. They may occur in any form of severe anaemia, but are 
especially marked in pernicious anaemia. 

DI3ILNISHED HAEMOGLOBIN. 

The diminution of haemoglobin is usually proportionate to 
the diminution of the red corpuscles, but there are two marked 
exceptions, namely, in chlorosis, in which the red corpuscles 
may be diminished only twenty or thirty per cent., while the 
haemoglobin is diminished fifty or sixty per cent., and in per- 
nicious anaemia, in which the red corpuscles are greatly dimin- 
ished, but are relatively rich in haemoglobin. 

MELANAE3IIA. 

Mel anaemia, the presence in the blood of free pigment, usu- 
ally results from chronic malarial infection. In rare instances 
it has been found associated with melano-sarcoma and Addi- 
son's disease. 



ANiEMIA. HI 



LIP^MIA. 



Lipaeniia, the presence in the blood of fine drops of fat, 
may be noted in health. It is also observed in alcoholism, 
ehyluria, and especially in diabetes. 

MICROORGANISMS IN THE BLOOD. 

The following microorganisms have been detected in the 
blood : The plasmodinm malariae, the filaria sanguinis hominis, 
the distoma haematobium, the spirillum of relapsing fever, 
and the bacillus of anthrax, glanders, typhoid fever, and 
tuberculosis. 

ANEMIA. 

Definition. — A condition in which the blood is diminished 
in quantity, or is deficient in one or more of its constituents. 

Varieties. — (1) Symptomatic or secondary anaemia. (2) 
Essential or primary anaemia. 

Symptomatic Anaemia. 

Etiology. — (1) Congenital — a constitutional tendency. (2) 
Bad hygiene — excesses, faulty diet, impure air, lack of sun- 
light. (3) Hemorrhage. (4) Organic disease — cancer, Bright's 
disease, phthisis. (5) Toxic agents — lead, malaria, syphilis. 

Pathology. — The blood is deficient in haemoglobin and 
corpuscles, and the tissues show fatty degeneration. 

Symptoms. General Symptoms. — Pallor of skin and mucous 
membranes, loss of flesh and strength, and, in severe cases, 
febrile paroxysms and ecchymoses. 

Circulation. — A full, soft, and rapid pulse, pulsation of the 
cervical vessels, palpitation of the heart, haemic murmurs, and 
slight dropsy beginning in the feet. 

Respiration. — Hu rried breath i ng. 

Digestion is weak. 

Nervous System. — Headache, vertigo, disturbed sleep, neu- 
ralgic pains, and a tendency to syncope. 



112 DISEASES OF THE BLOOD. 

Diagnosis. — Usually evident, but appearances are decep- 
tive, and an absolute diagnosis rests on the examination of the 
blood. 

Prognosis. — Depends on the cause. 

Treatment. — Removal of the cause, when possible. Good 
hygiene. The use of iron, arsenic, and general tonics. 

Essential, or Primary Ansemia. 

Definition. — Ansemia arising without obvious cause, or 
dependent upon faulty action of the blood-making organs. 

Varieties. — (1) Pernicious ansemia. (2) Chlorosis. (3) 
Leucocythaeinia. (4) Pseudo-leucocythaemia. 

PERNICIOUS ANEMIA 

(Idiopathic Ansemia, Progressive Pernicious Anaemia.) 

Definition. — A grave form of anaemia, often unassociated 
with any distinct causal lesions. 

Etiology. — Male sex, middle life, parturition ; and finally, 
symptomatic ansemia, resulting from its various causes, pre- 
dispose to it. 

Pathology. — As a result of the disease the organs reveal 
extensive fatty degeneration. Not infrequently atrophy of the 
gastric tubules is found as an adequate cause. In many cases 
an excessive amount of iron pigment has been found in the 
liver ; in others, hyperplasia of the red marrow of bone ; in 
others, pigmentation and degeneration of the sympathetic 
ganglia ; but the relation of these changes to pernicious 
ansemia is still undetermined. 

Symptoms. — The general symptoms of intense anaemia, 
with the following peculiar symptoms : A lemon-yellow tint 
to the skin, febrile paroxysms, little wasting, and often an in- 
crease in weight, and frequently gastric disturbances. 

The Blood. — Haemoglobin normal in amount or relatively 
increased ; great reduction in the number of red corpuscles, 
sometimes as much as 75 per cent, ; there is great diversity in 
the size and shape of the red corpuscles, some being small 
(microcytes), some large (megalocytes), some very large and 



CHLOROSIS. 113 

nucleated (giganto-blasts), and some irregular in outline 
(poikilocytes). The number of white corpuscles is not materi- 
ally changed. 

Prognosis. — Very unfavorable, the average duration being 
one to two years. Recovery occasionally occurs. 

Treatment. — Removal of any obvious cause. Good hy- 
gienic conditions; a nutritious and easily assimilable diet; 
rest; the use of iron and arsenic, especially the latter, gradu- 
ally increased to its physiological limit. 

CHLOROSIS. 

(Green Sickness, Primary Anaemia.) 

Etiology. — Puberty, girls, rarely boys ; bad hygiene, i. e. 
poor food, impure air, overwork, and lack of sunlight. 

Pathology. — Generally, no demonstrable causal lesions. 
In persistent cases, imperfect development of the large arteries 
and of the genitalia is sometimes found. 

Symptoms. — General manifestations of anaemia, with the 
following peculiar symptoms : The blood shows a moderate 
reduction of the number of red corpuscles, with a much greater 
reduction of the haemoglobin, and some irregularity in the size 
and shape of the corpuscles ; a pale-green tint to the skin, and 
a tendency to hysterical outbreaks and to menstrual disorders. 

These conditions, with the age and sex of the patient, deter- 
mine the diagnosis. 

Complications. — Gastric ulcer, phthisis, exophthalmic 
goitre, and amenorrhoea. 

Prognosis. — Favorable. 

Treatment. — Good hygienic conditions ; nutritious food ; 
iron in ascending doses, with the occasional use of some saline 
laxative. 

]£ Ferri sulph., 

Potass, carb., aa gr. xxxvj. — M. 
Ft. in pil. No. xxiv. 
Sig. -Three pills daily, increased to nine pills daily. 



114 DISEASES OF THE BLOOD. 

LEUCOCYTH^EMIA. 

(Leucaemia.) 

Definition. — A form of anaemia characterized by a great 
excess of the white corpuscles, with hyperplasia of the spleen 
or of the lymphatics, or changes in the bone-marrow. 

Etiology. — The causes are obscure. Male sex, middle life, 
malaria, heredity, bad hygiene, and repeated hemorrhages are 
predisposing factors. 

Pathology. — Three varieties are noted : (1) Splenic leu- 
caemia, in which the spleen is enlarged from congestion and 
hyperplasia. (2) Lymphatic leucaemia, in which the lymphatic 
glands are the seat of hyperplasia. (3) Myelogenic leucaemia, 
in which the medulla, especially of the ribs, sternum, and verte- 
brae, is converted into a pulpy material, ranging from a dirty 
yellow to a deep red color, according as the congestion or the 
excess of leucocytes predominates. 

Leucaemic tumors (collections of proliferated leucocytes) are 
frequently found in the various organs. The liver is often 
considerably enlarged. 

The tissues show fatty degeneration. 

Symptoms. — The general manifestations of anaemia, with 
the following peculiar symptoms : Enlargement of the lym- 
phatics or spleen, or tenderness over the bones, slight febrile 
paroxysms, dimness of vision from hemorrhagic retinitis or 
leucaemic deposits. 

The Blood. — A marked and persistent actual increase of the 
white corpuscles. The proportion may be 1 to 50 or even 1 to 10. 
The white cells vary in size and often lack amoeboid move- 
ment. Octahedral crystals, discovered by Charcot, are often 
found. The red corpuscles are somewhat diminished in number. 

Prognosis. — Recovery rarely follows. Death usually re- 
sults in from one to three years. 

Treatment. — Good hygienic conditions. The use of iron, 
quinine, and arsenic. Pern oval of the spleen has given nega- 
tive results. 



115 



PSEUDO-LEUCEMIA. 

(Hodgkins' Disease, Lymphatic Anaemia, Malignant Lymphoma.) 

Definition. — A form of anaemia characterized by a hyper- 
plasia of the lymphatic structures, without any increase of the 
white corpuscles. 

Etiology. — The causes are obscure. Male sex, early life, 
and simple adenitis seem to be predisposing causes. 

-Pathology. — There is hyperplasia of the lymphatic struc- 
tures; glands, spleen, and bone-marrow sharing in the process. 
New foci of lymphatic tissue are often noted- 

Symptoms. — The general manifestations of anaemia, with 
the following peculiar symptoms : Enlargement of the lym- 
phatic glands, which usually begins in the neck ; the glands 
comprising the lymphatic tumors remain distinct and freely 
movable, and rarely suppurate. The spleen is generally 
somewhat enlarged. Febrile paroxysms are common. The 
blood shows the signs of simple anaemia. 

Diagnosis. — Tuberculous glands may resemble the glands of 
pseudo-leucaemia, but the former are usually associated with 
tubercle in other parts of the body, and soon fuse together 
and suppurate. 

Pkognosis. — Very unfavorable. 

Treatment. — The same as for leucaemia. 

ADDISON'S DISEASE. 

Definition. — A constitutional disease, characterized ana- 
tomically by a degeneration of the suprarenal capsules or 
semilunar ganglia, and clinically by pigmentation of the skin, 
anaemia, and prostration. 

Etiology. — Male sex, middle life, and laborious work are 
predisposing factors. 

Pathology. — In most instances tuberculosis of the supra- 
renal capsules is discovered. Other affections, such as tumors 
and degeneration of the suprarenal capsules, may produce the 
disease. In a few instances degenerative changes in the 



116 DISEASES OF THE BLOOD. 

abdominal sympathetic ganglia have been the only discoverable 
lesions. 

Symptoms. — Moderate anaemia, with bronzing of the skin 
and mucous membranes, great weakness, and gastric irritability 
are its chief manifestations. 

Prognosis. — Unfavorable. Duration is one to two years. 

Treatment. — Rest and nutritious diet, with iron, arsenic, 
quinine, and strychnia. 

HAEMOPHILIA. 

(Bleeder's Disease, Hemorrhagic Diathesis.) 

Definition. — An hereditary disease, characterized by a 
tendency to bleed excessively from slight wounds, or even 
spontaneously. 

Etiology. — The great cause is heredity. It is more com- 
mon in males, but is usually transmitted by females, even by 
those who are not themselves afflicted. 

Pathology. — Unknown. In some instances the arteries 
have been found smaller than normal, with their walls thin 
and degenerated. 

Symptoms. — The chief symptom is free and persistent 
bleeding after trivial injury. Spontaneous hemorrhages from 
mucous membranes of the nose, stomach, bowel, etc., and sub- 
cutaneous extravasations are quite common. The only other 
symptom is a peculiar inflammation of the joints, resembling 
rheumatism. 

Prognosis. — Unfavorable. Grandidier states that one-half 
die before the eighth year, and less than one-eighth survive 
their twenty-first. In some instances the tendency is out- 
grown. 

Treatment. — Protective and palliative. For the bleeding 
apply cold compresses and styptics, and use internally ergot, 
hamamelis, or erigeron. The resulting anaemia will be bene- 
fited by iron. 



PURPURA HEMORRHAGICA. 117 

SCURVY. 

(Scorbutus.) 

Etiology. — Lack of fresh vegetables and bad hygienic 
surroundings are the predisposing causes. 

Pathology. — The pathogenesis of scurvy is unknown. 
Fatty degeneration from the anaemia, and widespread ecchy- 
moses are found after death. 

Symptoms. — The general manifestations of anaemia, with 
great weakness ; spongy, bleeding gums, fetor of the breath, 
and looseuing of the teeth ; subcutaneous ecchymoses, and 
hemorrhages from the mucous membranes ; and finally, a pain- 
ful, brawny induration of the muscles due to a sanguineous 
exudation. 

Prognosis. — Favorable in its earlier stages. 

Treatment. — Fresh vegetables and the free use of lemon- 
juice. Iron in moderate doses. Weak solutions of chlorate of 
potassium, or nitrate of silver may be applied to the bleeding 
gums. 

PURPURA HEMORRHAGICA. 

(Morbus Maculosus Werlhofii.) 

Definition. — A condition arising without obvious cause, 
and characterized by extravasation of blood in the skin and 
bleeding from the mucous membranes. 

Etiology. — Bad hygiene, early life, and female sex exert 
some predisposing influence ; but it may occur at any age and 
in the most robust of either sex. A microorganismal cause has 
been suggested. 

Pathology. — Unknown. 

Symptoms. — The onset may be marked by some fever, 
headache, malaise, and pain in the limbs; but these symptoms 
may be absent, and the disease ushered in with a copious crop 
of small hemorrhages into the skin, followed by bleeding from 
the mucous membranes. Anaemia and its associated phenomena 
develop in severe cases. 



118 DISEASES OF THE BLOOD. 

Diagnosis. — The absence of high fever and nervous symp- 
toms will separate it from typhus fever and cerebrospinal 
meningitis. The history and the absence of spongy gums and 
of brawny induration of the muscles will separate it from 
scurvy. Previous health and the absence of hereditary ten- 
dency separate it from hcemophilia. 

Prognosis. — Depends on the severity. Mild cases recover 
in from one to two weeks; severe cases may prove fatal in a 
few days from exhaustion or hemorrhage into the brain. Re- 
lapses are common. 

Treatment. — Rest, Light, nutritious food. Arsenic, 
iron, turpentine, and the fluid extract of hamamelis are the 
most serviceable remedies. 






DISEASES 



CIRCULATORY SYSTEM 



INSPECTION. 

Inspection detects the apex-beat, and determines its position, 
force, and extent ; any abnormal centres of pulsation ; and any 
unnatural prominence over the precordial region. 

The Apex-beat. 

The normal position of the apex-beat is in the fifth inter- 
costal space, about an inch within the mammary line (a line 
drawn from the middle of the clavicle parallel with the 
sternum). The beat is usually detected by inspection or pal- 
pation, but when these methods fail it may be localized by 
auscultation, the point in the region of the apex where the 
first sound is heard with maximum intensity corresponding 
to the beat. 

The Effect of Respiration and Position on the Apex-beat. — 
The location and force of the apex-beat are modified by the 
posture of the patient and the stage of the respiratory act. In 
the recumbent position the apex-beat may be elevated an inch 
or more, and when the body is inclined to the left, the heart 
being a more or less movable organ, the beat may be detected 
in the mammary line, or even some distance to its outer side. 

During forced inspiration the beat may become imper- 
ceptible, or if such is not the case it may be found some 
distance below its usual place, on account of the upward 

(119) 



120 DISEASES OF THE CIRCULATORY SYSTEM. 

movement of the ribs in the inspiratory act. Daring forced 
expiration, the air being driven from the lung-tissue in front 
of the heart, the beat becomes more forcible, and its position 
elevated on account of the descent of the ribs which occurs in 
expiration. 

In view of the influence exerted by respiration and position 
on the apex-beat the patient, as a rule, should be examined in 
the erect or sitting posture, while breathing quietly. 

Displacement of the Apex-beat. 

Displacement to the left may result from : — 

1 . Hypertrophy and dilatation of the heart (down and to 
the left.) 

2. Pericardial effusion (up and to the left). 

3. Chronic diseases of the left luug and pleura, associated 
with retraction — as fibroid phthisis and pleural adhesions. 

4. Abdominal tumors and effusions (up and to the left). 

5. The pressure of a pleural effusion on the right side (up 
and to the left). 

Displacement to the right may be caused by : — 

1 . Chronic disease of the right lung or pleura associated with 
retraction. 

2. Pressure of a pleural effusion on the left side. 
Displacement downward may result from : — 

1. Hypertrophy and dilatation of the heart, chiefly the left 
ventricle. 

2. Pressure of solid growths in the upper mediastinum. 

3. Aneurism of the aortic arch. 

4. Enlargement of the liver, causing traction through the 
central tendon of the diaphragm. (Paul.) 

Deformity of the chest may cause displacement in any 
direction. 



Changes in Force and Extent of the Apex-beat. 

The force and, extent may be increased by : — 
1. Hypertrophy of the heart. 



INSPECTION. 121 

2. Excited action of the heart, from drags, reflex irritation, 
excitement, or diseases, as exophthalmic goitre. 

3. Shrinking of the lungs, as in phthisis. 
A weak apex-beat may be noted in : — 

1. Healthy people. 

2. Degeneration or dilatation of the heart. 

3. Pericardial effusion. 

4. Emphysema. 

5. Shock or collapse. 

Abnormal Centres of Pulsation. 

Epigastric pulsation may result from : — 

1. Excited action of the heart from any cause. 

2. Enlargement of the right ventricle. 

3. A pulsating aorta noted in certain nervous and anaemic 
patients. 

4. Aortic aneurism. 

5. Tumors of the left lobe of the liver resting on the aorta. 
Pulsation at the base of the heart may result from : — 

1. Aneurism of the aortic arch. 

2. Cardiac hypertrophy. 

3. Shrinking of the lungs, as in phthisis. 
Pulsation in the left axilla may result from : — 

1 . Enlargement of the heart. 

2. A tense purulent effusion in the left pleural sac (pulsat- 
ing empyema). 

3. Aneurism. 

■ Unnatural pulsation in the carotids may result from : — 

1. Excitement of the heart from any cause. 

2. Exophthalmic goitre. 

3. Anaemia. 

4. Valvular disease, especially aortic regurgitation. 

5. Aneurism or dilatation of the vessels. 

6. Unnatural elasticity of the vessels, noted in certain ner- 
vous and anaemic patients. 



122 DISEASES OF THE CIRCULATORY SYSTEM. 



Jugular Pulsation. 

The jugular vein often becomes distended in forced expira- 
tion and coughing. Distention of the jugular vein is some- 
times noted in adherent pericardium. 

A true, rhythmical venous pulsation usually results from 
tricuspid regurgitation . 

A pulsation may be transmitted to the jugular vein from the 
underlying carotid, but this false pulsation will still continue 
when light pressure is made on the vein at the root of the 
neck, while the true venous pulse will cease. 

Precordial Prominence. 

Unnatural prominence of the prcecordia may result from : — 

1. Deformity. 

2. Enlargement of the heart. 

3. Pericardial effusion. 



PALPATION. 

This not only determines the position, force, extent, and 
rhythm of the apex-beat, but also detects the existence of any 
fremitus or thrill. 

A thrill is a vibratory sensation likened to that received 
when the hand is placed on the back of a purring cat. Thrills 
at the base of the heart may result from valvular lesions, athe- 
roma of the aorta, aneurism, and from roughened pericardial 
surfaces, as in pericarditis. 

A presystolic thrill at the apex is almost pathognomonic of 
mitral stenosis. 

PERCUSSION. 

This determines the shape and extent of the cardiac dulness. 

The normal area of superficial or absolute percussion-dulness 
(the part uncovered by lung) is detected by light percussion, 
and extends from the fourth left costo-sternal junction to the 



AUSCULTATION. 123 

apex-beat ; from the apex-beat to the junction of the xiphoid 
cartilage with the sternum and thence up the left border of 
the sternum. 

The normal area of deep per cuss ion-dulness (the heart pro- 
jected on the chest-wall) is detected by firm percussion, and 
extends from the third left costo-sternal articulation to the 
apex-beat; from the apex-beat to the junction of the xiphoid 
cartilage with the sternum; and thence up the right border of 
the sternum to the third rib. The lower level of the cardiac dul- 
ness fuses with the liver dulness, and can rarely be determined. 

The area of cardiac dulness is increased in : (1) Hypertrophy 
and dilatation of the heart. (2) Pericardial effusion. It is 
apparently increased in shrinking of the lungs, as in phthisis. 

The area of cardiac dulness is diminished in : (1) Emphy- 
sema. (2) Pneumothorax. (3) Pneumopericardium (rare). 
(4) Gaseous distention of the stomach. 

AUSCULTATION. 

This determines the quality, intensity, and rhythm of the 
heart-sounds, and detects the presence of any adventitious 
sounds, as murmurs. The two sounds heard over the heart have 
been represented by the syllables, " lubb, tup." The first sound 
(systolic) results from contraction of the ventricle, tension of 
the auriculo-ventricular valves, and the impact of the heart 
against the chest-wall, and is synchronous with the apex-beat 
and carotid pulse. This sound is prolonged and dull. After 
the first sound there is a short pause, and then follows the 
second sound (diastolic), which results from the closure of the 
aortic and pulmonary valves. This sound is short and high- 
pitched. After the second sound a longer pause follows be- 
fore the first is again heard. 

The Intensity of the Heart- sounds. 

Both sounds are accentuated in : (1) Excitement of the heart 
from any cause. (2) Anaemia. (3) Cardiac hypertrophy. 
(4) Subjects with thin chest-walls. (5) Consolidation of the 
lung, as in phthisis and pneumonia. 



124 DISEASES OF THE CTRCULAT6KY SYSTEM. 

Accentuation of the aortic second sound results from : (1) Hy- 
pertrophy of the left ventricle. (2) High arterial tension, as 
in arterio-selerosis and Bright' s disease. (3) Aortic aneurism. 

Accentuation of the pulmonary second sound results from : 

(1) Pulmonary obstruction, as in emphysema, pneumonia, and 
the congestion of the lungs following mitral disease. (2) Hy- 
pertrophy of the right ventricle. 

Weakness of both sounds is noted in : (1) General obesity. 

(2) General debility. (3) Degeneration or dilatation of the 
heart. (4) Pericardial or pleural effusion. (5) Emphysema. 

Reduplication of the Heart-sounds. 

This is probably due to a lack of synchronous action in the 
valves of the two sides of the heart, and results from many con- 
ditions, but notably from increased resistance in the systemic 
or the pulmonary circulation, as in arterio-selerosis of chronic 
nephritis and in emphysema. It is frequently noted in mitral 
stenosis and pericarditis. 

Adventitious Sounds or Murmurs. 

A murmur is an abnormal sound heard over the heart or 
bloodvessels, and may result from : (1) Obstruction or regur- 
gitation at the valves following endocarditis. (2) Dilatation 
of the ventricle or relaxation of its walls, rendering the valves 
relatively insufficient. (3) Aneurism. (4) A change in the 
blood constituents, as in anaemia. (5) Roughening of the 
pericardial surfaces, as in pericarditis. (6) . Irregular action 
of the heart. 

Murmurs produced within the heart are termed endocardial ; 
those produced outside, exocardial ; those produced in aneu- 
risms, bruits ; and those produced by anaemia, hsemic murmurs. 

Hsemic Murmurs. 

Haemic murmurs have the following characteristics : They 
are soft and blowing in character, usually systolic in time, 
heard best over the pulmonary valves, transmitted into the 






THE PULSE. 125 

carotids, accompanied with a hum in the veins of the neck, 
associated with the symptoms of anaemia, and disappear with 
the latter. 

Pericardial Friction- sounds. 

Pericardial murmurs, or friction-sounds, are superficial, 
rough and creaking in quality, to and fro in time, not trans- 
mitted beyond the prseeordia, aud may be modified by pressure 
of the stethoscope. 

The Aneurismal Murmur, or Bruit. 

This is usually loud and booming in character, systolic in 
time, heard best over the aorta or base of the heart, and is 
often associated with an abnormal area of clulness and pulsa- 
tion, and with symptoms resulting from pressure on neighbor- 
ing structures. 

THE PULSE. 

The average frequency of the pulse in the adult is between 
70 and 80 per minute At birth it is between 130 and 150; 
in the second year about 100, and so it gradually lessens as 
the child grows old. 

Increased frequency of the Pulse {Tachycardia). 

Habitual frequency is sometimes noted in health. The 
frequency may be temporarily increased by erect posture, ex- 
citement, eating, and the use of stimulants. 

Abnormal frequency may result from — (1) Pyrexia. The 
pulse usually bears a definite relation to the temperature, but 
in certain diseases, as scarlet fever and septicaemia, it is dispro- 
portionately rapid. (2) Exophthalmic goitre. (3) Organic 
heart-disease. (4) Pressure at the base of the brain sufficient to 
paralyze the pneumogastrics, as in clot, tumor, and advanced 
meningitis. (5) Shock. (6) Reflex irritation, as in dyspepsia, 
ovarian, or uterine disease. (7) An independent paroxysmal 
neurosis (" Essential Paroxysmal Tachycardia"). (8) Certain 
drugs — belladonna, nitrites, alcohol, etc. (9) Rheumatoid ar- 
thritis (Sansom). 



126 DISEASES OF THE CIRCULATORY SYSTEM. 

Infrequency of the Pulse (Brachycardia). 

Physiological sloivness is noted in repose, fasting, the puer- 
periuin, old age, and habitually in certain people (40 to 60 per 
minute). 

Pathological infrequency is observed in many conditions, 
notably — (1) In organic heart disease, especially fatty degen- 
eration and fibroid induration. (2) In jaundice. (3) From 
pressure at the base of brain sufficient to irritate the vagus, 
as in beginning meningitis. (4) At the close of febrile dis- 
eases, as typhoid fever, pneumonia, etc. (5) After the use of 
certain drugs, as digitalis, aconite, opium, etc. 

Irregular Rhythm. 

(Arhythmia.) 

The Intermittent Pulse,— This per se is not significant of 
any pathological condition. It is habitually noted in certain 
people, after exercise, eating, excitement, or the use of tobacco, 
tea, or coffee. It is frequently reflex from gastric, hepatic, 
uterine, or renal disease. It is common in lithsemia and fatty 
degeneration of the heart. 

There may be a false intermission or infrequency in the 
radial pulse when the heart fails to transmit all its beats to 
the wrist. This condition is usually indicative of a weak heart. 

The Irregular Pulse. — This has the same significance as the 
intermittent pulse. It is also very common in myocarditis 
and valvular disease, especially mitral regurgitation. 

Fig. 8. 




Sphygmogram of the trigeminal pulse. 



The Bigeminal and Trigeminal Pulses, — Two or three 
regular beats followed by a longer pause. They have the 
same significance as the irregular pulse. 



THE PULSE. 127 

The Pulsus Paradoxus. — One which is more or less sup- 
pressed at the close of each full inspiration. It is thought to 
be clue to the compression of the great vessels by inflammatory 
adhesions, the latter being stretched during the act of inspira- 
tion. It is frequently noted in adherent pericardium. 

The Dicrotic Pulse. — A pulse in which the main beat is 
quickly followed by a secondary wave or slight rebound of 
the vessel. The secondary or dicrotic wave results from a 



Fig. 9. 



VK 



Sphyginogram of a dicrotic pulse. 

recoil of the relaxed vessels after the latter have been dis- 
tended by a sharp ventricular contraction. It is indicative of 
low arterial tension, and is noted especially in febrile diseases 
and low states of the nervous system. 

Other Variations in the Pulse. 

The High-tension Pulse. — One in which the force of the 
beat is relatively increased. The tension may be roughly 
estimated by noting the amount of pressure of the fingers that 
is required to arrest the beat. 

A high-tension pulse is observed in many conditions, notably 
in cardiac hypertrophy, excitement of the heart, chronic ne- 
phritis ; in cerebral affections irritating the vaso-motor centre, 
such as apoplexy, tumors, and beginning meningitis ; after 
the use of certain drugs, as digitalis, ergot, and alcoholic 
stimulants ; in chills ; in pregnancy ; in certain neuroses, as 
angina pectoris, epileptic and hysterical seizures ; and from 
contraction of the capillaries by irritants generated in the body, 
as in lithsemia, gout, uraemia. 



128 DISEASES OF THE CIRCULATORY SYSTEM. 

The Low-tension Pulse. — This is also observed in many 
conditions, notably in degeneration of the heart, in collapse, 
in debility, in fevers, and in low states of the nervous system. 

Venous Pulse. — A true jugular pulsation is often noted in 
tricuspid regurgitation. A venous pulse in the dorsum of the 
hand may be due to (1) forcible propulsion of blood through 
the capillaries, as in aortic regurgitation with great hyper- 
trophy of the left ventricle ; or (2) to extreme relaxation of 
the arterioles and capillaries, permitting the transmission of 
the pulse-wave, as in grave cachexia and anaemia. 

Asymmetrical Radial Pulses. — May result from : (l) 
Anomalies in the distribution, size, and division of one of 
the vessels. (2) Aortic aneurism. (3) An embolism or an 
atheromatous plate within the vessel. (4) Fractures, luxations, 
or inflammatory exudations causing compression of the vessel. 
(5) Compression of one vessel by tumors within or without 
the thorax. 

{ ( Water-hammer Pulse " ( C brriga n's Pulse). — Characterized 
by a short, powerful beat, which suddenly collapses. The 
peculiar pulsation may be distinctly visible, not only in the 
carotids but throughout the brachial artery. This pulse is 
diagnostic of aortic regurgitation during the period of compen- 
sation, and its force is due to the excessive ventricular hyper- 
trophy and to the large amount of blood expelled with each 
systole ; its sudden recession is due to the incompetent valves 
failing to support the column of blood. 

PALPITATION. 

Definition. — A rapid and tumultuous action of the heart 
perceptible to the patient. Rapidity not perceptible to the 
patient is not termed palpitation. 

Etiology. — It may result from : (1) Reflex irritation, as 
from gas or acid in the stomach. (2) Excitement, mental 
or physical. (3) Organic heart disease. (4) Exophthalmic 
goitre. (5) Over-work, as in the " irritable heart" of un- 
trained recruits. (6) Anaemia. (7) Hysteria. (8) An inde- 
pendent neurosis (Essential Paroxysmal Tachycardia). 



DROPSY GENERAL CYANOSIS. 129 



DROPSY. 

Definition. — An unnatural collection of serous fluid in 
the tissues or cavities of the body. 

Etiology. — Dropsy results from : (1) Venous stasis, from 
chronic heart, liver, and lung diseases, and from local obstruc- 
tion to the venous circulation by tumors, pregnant uteri, or 
varicose conditions. The last is a common cause of oedema 
in the legs of old people. (2) Alterations in the blood or 
capillaries, as in Bright's disease, anaemia, and inflammation. 
Cardiac dropsy usually begins in the feet and ascends. 

GENERAL CYANOSIS. 

Definition. — Blueness of the surface from insufficient oxi- 
dation of the blood. 

Etiology. — Cyanosis results from : (1) Conditions which 
obstruct the entrance of air, as croup ; oedema of the larynx ; 
tumors or foreign bodies in the air-passages; tumors pressing on 
the air-passages; emphysema; pneumonia; pleurisy; paralysis 
of the respiratory muscles, as in bulbar palsy ; and spasm of 
the respiratory muscles, as in epilepsy, tetanus, etc. (2) An 
inability to get blood to the air, as in all forms of chronic 
heart disease ending in pulmonary congestion. 

Congenital Cyanosis is usually associated with stenosis of 
the pulmonary orifice, an imperfect ventricular septum, or a 
patulous foramen ovale; it probably results not so much 
from direct mixture of venous and arterial blood, as from the 
failure of the blood to reach the lung, or from general venous 
congestion. 



180 DISEASES OF THE CIKCULATOKY SYSTEM. 



PERICARDITIS. 

Definition. — An inflammation of the pericardium, or 
serous covering of the heart. 

Etiology. — (1) Idiopathic, from exposure. (2) Traumatic. 
(3) Secondary to neighboring inflammations, as pleurisy, 
phthisis, pneumonia, mediastinal disease. (4) Secondary to 
some general disease, as rheumatism, Bright's disease, septi- 
caemia, tuberculosis, and the eruptive fevers. 

Pathology. — In the early stage the membrane is red, 
sticky and lustreless; and if the process now ceases, the con- 
dition is termed dry pericarditis. 

If, however, the inflammation continues, an exudate is 
formed which may be: (1) Sero-fibrinous, (2) fibrinous, or 
(3) purulent. In the sem-fibrinous form there is little 
lvmph, the exudate being mainly composed of straw-colored 
serum (a few ounces to several pints), which in favorable cases 
is gradually absorbed. 

In the fibrinous form, serum is scant and the membrane is 
covered with a butter-like exudate, which subsequently or- 
ganizes and unites more or less closely the pericardial surfaces, 
pausing adherent pericardium. The adhesions offer resistance 
to the ventricular contractions and ultimately induce cardiac 
hypertrophy. In rare instances the fibrinous exudate becomes 
calcified. 

In the purulent form, death usually results ; but evacua- 
tion of the pus may be followed by union of the pericardial 
surfaces, and ultimate recovery. 

Symptoms. — Moderate fever, precordial pain and tender- 
ness, dry cough, dyspnoea, and palpitation. The pulse is at 
first rapid and forcible, but later weak and irregular. 

Physical Signs. First Stage. — Dry pericarditis. 

Inspection. — Negative. 

Palpation. — Sometimes a fremitus, from the grating of the 
roughened pericardial surfaces. 

Percussion. — Negative. 



PERICARDITIS. 131 

Auscultation — A superficial to-and-fro friction-sound, usu- 
ally heard best at the base of the heart and not transmitted, 
to any extent, beyond the praecordia. 

Second Stage. — Sero-fibrinous effusion. 

Inspection. — Bulging of the praecordia. 

Palpation. — The apex-beat is feeble or lost. If detected, 
it is pushed upwards and to the left. 

Percussion. — Increased area of dulness, triangular in shape 
with the base down. 

Auscultation. — The heart-sounds are muffled, feeble, and 
distant. 

Purulent effusion yields similar signs, but in addition, — 
(1) the symptoms of hectic fever, viz: high and irregular 
fever, sweats, chills, and progressive pallor. (2) Sometimes 
oedema over the praecordia ; and, (3) in doubtful cases, the 
aspirating needle reveals pus. 

Fibrinous pericarditis (Adherent pericardium) is often diffi- 
cult to recognize, and while the following signs suggest the 
condition, they are not absolutely diagnostic : — 

Precordial bulging, a weak apex-beat with loud sounds, a 
systolic retraction or dimpling not only at the apex, but over a 
large part of the praecordia, a peculiar diastolic collapse of the 
jugular veins (Friedreich), a feeble apex-beat, with a forcible 
impulse over the body of the heart (Paul). 

With these signs there are often symptoms of heart-failure, 
such as dyspnoea, dropsy, and cyanosis. 

Diagnosis. Acute Endocarditis. — The murmur is soft and 
blowing, not harsh ; it is usually single, not to-and-fro ; it is 
somewhat distant, not superficial ; it is not necessarily heard 
best at the base, but at one of the valve points ; it is not con- 
fined to the praecordia, but is usually transmitted ; and it is not 
followed by the signs of effusion. 

Pericardial effusion must be distinguished from cardiac hy- 
pertrophy. In hypertrophy the area of dulness is increased, 
but normal in outline; the apex-beat is displaced downwards 
and to the left, and is forcible ; and the sounds are loud and 
clear. 

Pericardial effusion and cardiac dilatation. — In dilatation 
there is no friction-sound ; the apex is usually displaced down- 



132 DISEASES OF THE CIRCULATORY SYSTEM. 

wards, never upwards ; the area of dulness is not pyramidal, 
but extends laterally; the sounds are not muffled, but clear 
and sharp. 

Prognosis. — In the dry and sero-fibrinous forms the prog- 
nosis is good under favorable conditions. In the purulent 
form the outlook is extremely grave. The fibrinous form, 
though not immediately fatal, is very serious on account of the 
secondary changes which it induces in the cardiac muscle. 

Treatment. — Absolute rest. Light diet. Opium is usu- 
ally required to insure quiet and to relieve pain. When the 
action of the heart is rapid and irregular, either aconite or 
digitalis may be administered according to the strength of the 
pulse. 

Local Treatment. — In severe cases apply a few wet cups, 
leeches, or a blister to the prsecordia. In other cases, an ice- 
bag or poultice may give relief. 

Pericardial effusion (Chronic pericarditis). — When the effu- 
sion is decided, apply small blisters over the praecordia, admin- 
ister iodide of potassium (gr. x thrice daily), and encourage 
diuresis with digitalis or caffeine, and catharsis with saline 
draughts. 

(1) When the effusion is very large, (2) when it creates 
much disturbance, as dyspnoea, cyanosis, and the like, (3) 
when its absorption cannot be accomplished by internal reme- 
dies, or (4) when it is purulent, paracentesis of the peri- 
cardium is indicated. The needle should be introduced in the 
fifth interspace, a little to the right of the point of the normal 
apex-beat. When the effusion is purulent, a free incision offers 
a slight, and the only chance of cure. 

In adherent pericardium, repeated small blisters may be 
employed and heart-failure should be combated with digitalis 
and similar cardiac tonics. 

OTHER AFFECTIONS OF THE PERICARDIUM. 

Hydropericardium (Dropsy of the pericardium) results from 
pericarditis, or from one of the causes of general dropsy, as 
chronic heart, kidney, or lung disease. 

Physical Signs. — The same as sero-fibrinous pericarditis. 



ENDOCARDITIS. 133 

Hsemopericardium (Blood in the pericardial sac) results 
from the rupture of an aneurism, rupture of the heart, trau- 
matism, and cancerous and tuberculous pericarditis. 

Physical Signs. — The same as hydropericardium. It is 
speedily fatal. 

Pneumopericardium (Air in the pericardium). — This rare 
condition results from external wounds, or the rupture of an 
air-containing organ into the pericardium, as the perforation 
of a pyo-pneumothorax into the pericardial sac. The entrance 
of a septic irritant produces pus and the condition becomes a 
pneumo-pyoperieardium. 

Physical Signs. — Percussion over the praeeordia yields 
tympany ; and auscultation, splashing and metallic sounds. 

ENDOCARDITIS. 

(Valvulitis.) 

Definition. — Inflammation of the lining membrane of the 
heart. The process is usually confined to the valves. 

Varieties. — (1) Exudative, or vegetative endocarditis 
(Endocarditis verrucosa). This begins as an acute affection, 
but usually leads to chronic interstitial valvulitis. (2) Sclerotic, 
or interstitial valvulitis (Chronic endocarditis). (3) Ulcerative, 
or malignant endocarditis. 

Etiology. — Rheumatism is the chief cause. At least 50 
to 60 per cent, of all cases of acute rheumatism will be com- 
plicated with endocarditis. It is more liable to complicate 
rheumatism in the young than in the old. There is no rela- 
tion between the severity of the rheumatic disease and the 
liability to heart complication. The specific fevers, chorea, 
septicaemia, Bright's disease, syphilis, tuberculosis, alcoholism, 
and excessive muscular exertion, are also predisposing causes. 
It may be congenital. It rarely, if ever, results from expo- 
sure to cold and wet. 

Pathology. — Post-natal endocarditis most commonly in- 
volves the valves of the left side of the heart. 

Pre-natal endocarditis most commonly involves the valves 
of the right side of the heart. 

In the exudative form the valve is red, swollen, lustreless. 



134 DISEASES OF THE CIRCULATORY SYSTEM. 

and studded with numerous bead-like vegetations whieh are 
especially marked along its free margins. 

These vegetations are composed of proliferated connective- 
tissue cells, the superficial layers of which have undergone 
coagulation-necrosis, and are covered with more or less fibrin 
derived from the blood. 

They may be whipped off by the blood-current, and be 
carried as emboli to distant organs, as the brain, kidney, and 
spleen ; but more commonly, if life is preserved, they are 
partially absorbed, and the remaining proliferated connective- 
tissue cells form fibrous tissue, and thus sclerotic valvulitis is 
secondarily induced. 

Sclerotic valvulitis may arise as a primary disease, and is 
characterized by thickening, curling and puckering of the 
valve from an overgrowth of fibrous tissue, which is often as- 
sociated with more or less fatty degeneration of the cells and 
a deposition of lime salts in their midst. 

Symptoms of Acute Endocarditis. — Subjective phe- 
nomena are often absent, and auscultation may furnish the 
only indication of endocarditis, namely, a prolongation of the 
heart-sound, which later develops into a distinct murmur. 

In many cases fever, an irregular and rapid pulse, palpita- 
tion, precordial distress, and dyspnoea will be associated symp- 
toms. 

Diagnosis. — By signs alone. In pericarditis, the friction- 
sound is to-and-fro, superficial, perhaps modified by pressure 
of the stethoscope, not transmitted much beyond the pra?- 
eordia, and is followed by signs of effusion. 

Prognosis. — In simple endocarditis the prognosis should 
be guarded. The lesion rarely disappears, and permanent 
damage to the valve results. Under favorable conditions, 
however, compensatory hypertrophy of the heart results, and 
good health may be preserved for an indefinite period. 

Treatment. — Absolute rest. Treat the causal condition. 
When the symptoms are marked, apply blisters, mustard 
poultices, leeches, or ice-bags to the praecordia. 

Support the system with moderate doses of quinine. When 
the pulse is weak and irregular, the tincture of digitalis (5 to 
10 drops) will be of great value. If the pulse is rapid and 



CHRONIC VALVULAR AFFECTIONS. 135 

strong, aconite may be employed instead of digitalis. Absor- 
bents like the iodides are of no value. Convalescence should 
be prolonged and guarded, so that compensatory hypertrophy 
may result. 

CHRONIC VALVULAR AFFECTIONS. . 

Period Of Compensation. — By compensation is meant an in- 
crease in the size and strength of certain cardiac chambers 
sufficient to enable the arterial system to receive its normal 
amount of blood, notwithstanding obstruction or regurgitation 
at one or more of the valves. 

The duration of this period is indefinite, and depends largely 
on the amount of damage sustained by the heart and the hy- 
gienic conditions to which the patient is subjected. 

During perfect compensation, subjective symptoms are absent, 
and physical signs indicate the disease. 

Aortic Stenosis, or Aortic Obstruction. 

Definition. — Obstruction to the flow of blood into the 
aorta from thickening or adhesion of the aortic segments. 

Physical Signs. Inspection. — If the heart is strong, the 
apex-beat is forcible, and is noted downward and to the left. 

Palpation confirms inspection, and sometimes detects a sys- 
tolic thrill at the base of the heart. 

Percussion may yield an increased area of cardiac dulness, 
especially to the left. 

Auscultation. — A systolic murmur with maximum intensity 
in the right second intercostal space, and transmitted into both 
carotid arteries. 

Pulse. — During perfect compensation, the pulse is quite 
normal, but when the heart weakens, it becomes small and 
slow. 

Compensation. — From obstruction to the outflow of blood, 
the left ventricle becomes hypertrophied. 

Sequence. — Mitral regurgitation. Weakening and dilata- 
tion of the left ventricle prevents perfect closure of the mitral 
orifice, and relative insufficiency results. 



136 DISEASES OF THE CIRCULATORY SYSTEM. 



Aortic Insufficiency, or Aortic Regurgitation. 

Definition. — Failure of the aortic valves to prevent a re- 
turn of blood to the ventricle, from rupture or inflammatory 
contraction of the segments, or from dilatation of the orifice. 

Physical Signs. Inspection. — Apex-beat forcible, and 
noted far downward and to the left. The prsecordia may bulge. 

Palpation. — Confirms inspection. 

Percussion. — Increased area of cardiac dulness, especially to 
the left. 

Auscultation. — A diastolic murmur with maximum intensity 
in the right second intercostal space, aud transmitted down the 
sternum and towards the apex. 

Pulse. — The arteries, especially the carotids, brachials, and 
radials, pulsate visibly. Palpation detects the " water-hammer," 
or Corrigan's pulse, i. e., a short, full, and receding pulse. 

The extreme cardiac enlargement makes the pulse full, and 
the prompt leakage back into the ventricle makes it short and 
receding. Elevation of the arm, during palpation of the radial, 
makes this pulse more apparent, as the position favors regur- 
gitation. A capillary pulse is sometimes present. It may be 
noted at the root of the finger-nail by an alternate blushing 
and paling, synchronous with the heart-beats. 

Compensation. — Dilatation and hypertrophy of the left 
ventricle. Dilatation results from the reception of such a large 
quantity of blood during diastole, and hypertrophy follows 
from the increased effort which the ventricle must put forth 
in emptying itself of this extra quantity of blood. 

This extremely dilated and hypertrophied heart has been 
called the cor bovinum, or ox-heart. 

Sequence. — Mitral regurgitation. The dilatation and 
weakening of the ventricle prevent perfect closure of the 
mitral orifice, and relative insufficiency results. 

Mitral Stenosis, or Mitral Obstruction. 

Definition. — Obstruction to the flow of blood through the 
mitral orifice, from thickening or adhesion of the mitral 
segments. 



CHRONIC VALVULAR AFFECTIONS. 137 

Physical Signs. Inspection. — Apex-beat is not much 
displaced. There is sometimes bulging over the lower part of 
the sternum. 

Palpation. — A rough presystolic thrill near the apex. 

Percussion. — Increased area of dulness, especially to the 
right. 

Auscultation. — A prolonged, rough, churning murmur, 
presystolic in time, heard most distinctly a little above and 
to the left of the apex, and not transmitted. 

The second sound at the pulmonary cartilage is accentuated 
from the enlargement of the right ventricle. 

Pulse. — During the period of compensation the pulse is 
small and regular. 

Compensation. — From obstruction to the outflow of blood 
the left auricle becomes enlarged • when it loses power, the 
blood accumulates in the lung, and to overcome this pulmonary 
resistance the right ventricle becomes hypertrophied. 

There is no strain on the left ventricle, and hence that cham- 
ber is not enlarged. 

Sequence. — Tricuspid regurgitation. Dilatation of the 
right ventricle prevents perfect closure of the tricuspid orifice, 
and relative insufficiency results. 

Mitral Insufficiency, or Mitral Regurgitation. 

Definition — Imperfect closure of the mitral orifice from 
rupture or inflammatory contraction of the mitral segments ; or 
from dilatation or weakening of the left ventricle, preventing 
perfect coaptation of normal valves. 

Physical Signs. Inspection. — Apex-beat forcible, and 
noted downward and to the left. The prsecordia may bulge. 

Palpation confirms inspection. 

Percussion. — Increased area of dulness to the right and 
left. 

Auscultation. — A systolic murmur, with maximum inten- 
sity at the apex, and transmitted to the left axilla and to the 
angle of the scapula. 

Pulse. — During period of compensation normal, but very 
irregular when the heart weakens. 



138 DISEASES OF THE CIRCULATORY SYSTEM. 

Compensation. — The left auricle enlarges from the extra 
amount of blood that it receives ; when it weakens, the lungs 
become congested and right ventricular hypertrophy follows. 

The left ventricle also becomes hypertrophied from its effort 
to move the large quantity of blood which it receives from the 
distended auricle during each diastole. 

Sequence. — Tricuspid regurgitation. Weakening and dila- 
tation of the right ventricle prevent perfect closure of the tri- 
cuspid orifice. 

Tricuspid Stenosis, or Tricuspid Obstruction. 

This lesion is comparatively rare. It gives rise to enlarge- 
ment of the heart and a presystolic murmur, which is heard 
most distinctly at the xiphoid cartilage. 

Tricuspid Insufficiency, or Tricuspid 
Regurgitation. 

Definition. — Imperfect closure of the tricuspid orifice 
from inflammatory shortening of the valves; or, more com- 
monly, from dilatation of the right ventricle secondary to 
mitral disease or to chronic lung disease. 

Physical Signs. — Enlargement of the heart; a systolic 
murmur, heard most distinctly just above the xiphoid cartilage, 
and associated with pulsation of the jugular vein, and in bad 
cases, with pulsation of the liver. 
i 

Pulmonary Stenosis, or Pulmonary Obstruction. 

This very rare lesion is always congenital, and may be sus- 
pected when a systolic murmur is heard most distinctly at the 
left second intercostal space, and is not transmitted into the 
vessels of the neck. 

Pulmonary Insufficiency, or Pulmonary 
Regurgitation. 

This is very rare, and is always congenital. It produces a 
diastolic murmur, which is heard most distinctly in the left 
second intercostal space. 



CHRONIC VALVULAR AFFECTIONS. 139 

Period of Lost Compensation. — Lost compensation usually 
results from: (1) Increasing damage to the valves ; (2) senility, 
leading to arterial and cardiac degeneration ; (3) some inter- 
current disease, throwing additional strain on the heart; and 
(4) undue physical exertion. 

During this period subjective symptoms appear. When the 
heart weakens, no matter what the original valvular lesion 
was, it becomes unable to fill the arteries, and the blood is 
dammed back in the lungs, and venous congestion of the 
organs follows. 

Symptoms. — Pulmonary congestion produces dyspnoea, 
asthma, haemoptysis, and often chronic bronchial catarrh with 
cough and expectoration. 

Hepatic, stomachic, and intestinal congestion produce dys- 
pepsia. Renal congestion produces scanty albuminous urine, 
and later nephritis. 

General venous congestion produces cyanosis, and dropsy 
which begins in the feet and mounts upwards. 

Cerebral anaemia or congestion produces headache, vertigo, 
and syncopal attacks. 

In aortic disease, especially aortic stenosis, cerebral symp- 
toms are often marked. In mitral disease, pulmonary symp- 
toms are usually marked. 

Prognosis of Chronic Valvular Affections. — The 
extent of damage can never be accurately determined by the 
quality or intensity of the murmur. 

All things being equal, the following is probably the order 
of- gravity in the. various valvular lesions: (1) Tricuspid re- 
gurgitation, (2) aortic regurgitation (often ending in sudden 
death), (3) aortic stenosis, (4) mitral stenosis, and (5) mitral re- 
gurgitation. 

The following are unfavorable conditions : Early life, ad- 
vanced years, great cardiac enlargement, irregular heart-action, 
liability to recurring attacks of rheumatism, bad hygienic 
surroundings, and symptoms of congestion of the lungs, kid- 
ney or digestive tract. 

In proportion to the absence of these conditions, the prog- 
nosis becomes favorable. In many cases life is not materially 
shortened. 



140 DISEASES OF THE CIRCULATORY SYSTEM. 

Treatment. — When compensation is perfect, the treat- 
ment is purely hygienic. 

When there is sudden heart-failure in valvular disease, in- 
dicated by orthopncea and cyanosis, rest should be absolute, 
hot applications should be applied to the prsecordia, and diffu- 
sible stimulants administered hypodermically : spirits of am- 
monia (20-30 minims), whiskey (30-60 minims), sulphate 
of strychnia (gr. ^, repeated once or twice), and especially 
nitro-glycerine (1-2 drops of one per cent, alcoholic solution) 
may be so employed ; the last, in addition to being a highly 
diffusible stimulant, has the power of dilating the peripheral 
bloodvessels. Venesection (10-20 ounces) is of extreme value 
in these cases. 

When compensation is gradually lost, rest, a light, nutritious 
diet, and tinct. digitalis (10-20 drops three or four times daily) 
are the most important therapeutic measures. Tinct. strophan- 
tus sometimes succeeds when digitalis fails. Mild laxatives, 
such as massa hydrargyri (gr. 3-5), greatly influence the 
absorption of digitalis. When there is moderate dropsy the 
following pill is very efficient : — - 

]£: Mass. hydrargyri, 

Pulv. digitalis, 

Pulv. scillse, aa gr. xxiv. — M. 
Ft. in pil. No. xxiv. 
Sig. — One pill thrice daily. 

Strychnine is often a valuable adjunct to digitalis, especially 
when there are indications of fatty degeneration of the heart. 
When there is anaemia, iron is indicated, and it may be given 
with digitalis and strychnine, as in the following pill : — 

I$l Strychnin, sulph., 

Pulv. digitalis, 

Ferri carb., aa gr. xxx. — M. 
Ft. in pil. No. xxx. 
Sig. — One pill thrice daily. 

When there is much bronchitis and dyspnoea, digitalis with 
ammonia and senega is an efficient combination. (Barlow.) 
When dyspnoea is marked and the pulse is strong, nitro- 
glycerine (1-2 drops thrice daily, or gr. T ^ thrice daily), if 
w r ell borne, may be of much service. In extreme dropsy 



ACUTE ULCERATIVE ENDOCARDITIS. 141 

free catharsis should be induced by compound jalap powder 
(gr. xx-xxx), or a concentrated solution of Epsom salts (,?ss), 
and diuresis established by the infusion of digitalis (f .1 ss-f,?j, 
thrice daily). In persistent anasarca, aspiration of serous sacs 
and puncture of the legs may be required. 

When there is excessive hypertrophy, indicated by precor- 
dial distress and a full, regular pulse, without dropsy, aconite 
in small doses will prove efficient. 

ACUTE ULCERATIVE ENDOCARDITIS. 

(Malignant Endocarditis.) 

Definition. — A rapidly-destructive form of endocarditis, 
characterized by necrosis or ulceration of the valves and the 
deposition of colonies of micrococci. 

Etiology. — It may begin as a primary disease, or be 
engrafted on a simple endocarditis. It may result in the de- 
bilitated from overwork or exposure ; it sometimes complicates 
the puerperium ; it generally follows septicaemia or one of the 
specific fevers — such as pneumonia, erysipelas, and scarlet 
fever. 

Pathology. — The valves are the seat of ulcers, deep ab- 
scesses, and soft, yellowish vegetations, which have undergone 
partial necrosis. Microscopic examination reveals myriads of 
micrococci. 

Symptoms. 1. General. — High and irregular fever, re- 
peated chills, profuse sweats, great prostration, often delirium 
and stupor, hurried breathing, rapid irregular pulse, brown 
fissured tongue. Jaundice and diarrhoea are frequently present. 

2. Cardiac Symptoms. — Precordial pain, palpitation, and 
often a blowing murmur at one or more of the valves. Mur- 
murs may be absent. 

3. Embolic Symptoms. — Peripheral emboli yield a petechial 
rash ; renal embolism may yield bloody urine ; splenic em- 
bolism may yield a painful spleen ; cerebral embolism may 
yield paralysis. 

Diagnosis. — Is often difficult. 

Meningitis. — Cardiac symptoms, high fever, profuse sweats, 
and chills will usually separate it from meningitis. 



142 DISEASES OF THE CIRCULATORY SYSTEM. 

Typhoid Fever. — Abrupt onset, cardiac symptoms, embolic 
symptoms, sweats, chills, and the absence of an abdominal 
rose-colored rash will separate it from typhoid fever. 

Malarial Fever. — In endocarditis the pJasmodium malarias 
is not found in the blood. 

Prognosis. — Almost invariably fatal. Duration is from a 
few days to several weeks. 

Treatment. — Ice-bags to the heart. Light nutritious diet. 
Stimulants. 

ACUTE MYOCARDITIS. 

Definition. — Acute inflammation of the heart muscle. 

Etiology. — It is almost always secondary to endocarditis 
or to pericarditis. As a primary affection of the heart, it 
may be due to rheumatism, or to one of the infectious fevers. 

Pathology. — The muscle substance is pale, flabby, and 
friable. Microscopic examination reveals fatty degeneration 
of the muscle fibres and an infiltration of the connective tis- 
sue with leucocytes. 

Symptoms. — The symptoms are often masked by the pri- 
mary disease. Dyspnoea, precordial pain and distress, a weak, 
very rapid, small, and irregular pulse, a feeble impulse, and 
weak sounds suggest the condition. 

Treatment. — Absolute rest, and the use of cardiac stimu- 
lants, like strychnia, caffeine, digitalis, and alcohol. 

FIBROID HEART. 

(Myodegeneration of the Heart, Chronic Myocarditis, Indurated 
Degeneration.) 

Etiology. — This condition is dependent upon atheroma or 
sclerosis of the coronary arteries. The indirect causes are 
rheumatism, gout, syphilis, alcoholism, endocarditis and peri- 
carditis. 

Pathology. — The heart is usually hypertrophied or 
dilated, and is the seat of grayish-white patches, which repre- 
sent overgrown connective tissue. The papillary muscles, 






HYPERTROPHY OF THE HEART. 143 

col iiiume carnese, and the wall of the left ventricle near the 
apex are the parts most frequently affected. 

Arterial sclerosis causes necrosis, and this in turn is followed 
by a proliferation of the connective tissue. 

The fibroid areas sometimes yield to the endocardial pres- 
sure and cause aneurism of the heart. 

Symptoms. — It manifests the same symptoms as fatty de- 
generation, viz : dyspnoea, cough, weak and irregular pulse, 
palpitation, anginoid pains, dropsy, etc. 

Treatment. — Same as in fatty heart. 

HYPERTROPHY OF THE HEART. 

Definition. — Enlargement of the heart due to an over- 
growth of its muscle. 

Etiology. — It always results from increased work, and 
this may be due to : (1) Too much blood to. be moved from 
the heart, as in the regurgitant valvular lesions. (2) Obstruc- 
tion to the outflow of blood at the valves, as in the stenoses ; or 
in the pulmonary or the systemic circulation, as in emphysema 
and Bright's disease. (3) Resistance to ventricular contrac- 
tion by pericardial adhesions. (4) Undue physical exertion 
long continued. (5) Disturbed innervation from drugs, such 
as tobacco ; or from disease, as exophthalmic goitre. 

Varieties. — (1) Simple hypertrophy. Thickened muscle 
and cavities of normal size. (2) Eccentric hypertrophy (hyper- 
trophy with dilatation). Thickened muscle and cavities di- 
lated. (3) Concentric hypertrophy. Thickened muscle and 
cavities diminished in size. Always congenital. 

Pathology. — The average weight of the normal heart is 
eight or nine ounces ; in hypertrophy it may weigh two or 
three times as much. One or both chambers may be enlarged ; 
the left is the one most commonly affected. The muscle is 
firm and of a deep red color. Histologically the muscle-ele- 
ments are increased in size and number. 

Symptoms. — Unless the hypertrophy is more than compen- 
satory no symptoms result. Extreme hypertrophy is indicated 
by precordial distress, palpitation, a strong pulse, and some- 
times by the phenomena of cerebral hyperemia, viz : flushed 



144 DISEASES OF THE CIRCULATORY SYSTEM. 

face, ringing in the ears, flashes of light, headache, and dis- 
turbed sleep. 

Physical Signs. Inspection. — Precordial bulging. For- 
cible impulse. The apex-beat is displaced downward and to 
the left. 

Palpation. — A heaving impulse. 

Percussion. — Increased area of cardiac dulness. 

Auscultation. — Sounds are dull and loud. 

Sequelae. — Apoplexy, fatty degeneration of the heart and 
subsequent dilatation, valvular disease, and arterial degeneration. 

Diagnosis. — Hypertrophy and dilatation. These two con- 
ditions are commonly associated, but the preponderance of di- 
latation will be indicated by a feeble fluttering impulse, weak 
sounds, a weak, irregular, or intermittent pulse, and by symp- 
toms of heart-failure, such as dyspnoea, dropsy, etc. 

Treatment. — When the hypertrophy is excessive, recom- 
mend graduated exercise and a light diet, and employ such seda- 
tives as tincture of aconite (gtt. j-ij thrice daily) or tincture of 
veratrum viride (gtt. j-ij). The bromides are often valuable 
adjuncts. 

DILATATION OF THE HEART. 

Definition. — Enlargement of the heart due to stretching 
of its walls. 

Varieties.— (1) Dilatation with thickening of the walls 
(eccentric hypertrophy), and (2) Dilatation with thinning of 
the walls. 

Etiology. — Dilatation results from excessive endocardial 
pressure, as in sudden extreme exertion and in valvular disease, 
and (2) Impaired nutrition of the cardiac muscle, as in low 
fevers, valvular disease, and atheroma of the coronary arteries. 

Pathology. — One or both chambers may be dilated ; the 
right is the one most commonly affected. The condition is usu- 
ally associated with hypertrophy and fatty degeneration. The 
muscle may be normal in appearance, but very frequently it is 
pale and soft. 

Symptoms. — So long as the associated hypertrophy keeps 
pace with the dilatation, no symptoms result ; but when dila- 
tation preponderates, the following symptoms of venous 



FATTY DEGENERATION OF THE HEART. 145 

stasis appear : dyspnoea, cough, dyspepsia, scanty urine, dropsy, 
and a feeble, irregular pulse. 

Disturbed innervation often causes precordial distress and 
palpitation. 

Physical Signs. — Apex-beat is diffuse and weak ; it may 
be visible and yet not palpable (Walshe). When the right 
heart is involved an impulse is noted below the xiphoid carti- 
lage. 

Palpation. — A diffuse, feeble, and fluttering impulse. 

Percussion. — The area of dulness is increased, especially 
laterally. 

Auscultation. — The sounds are weak and sharp. The first 
sound loses its muscular element and resembles the second. 
Co-existing valvular lesions induce murmurs. 

Diagnosis. — Pericardial effusion. In this condition a fric- 
tion-sound is frequently present ; the outline of dulness is py- 
riform with the base below, and is not nearly so broad as in 
dilatation ; and the sounds are distant and muffled ; and the 
apex-beat is displaced upwards. 

Treatment. — Rest. Light and nutritious diet. Improve 
the general condition by careful hygienic regulations, and the 
use of such tonics as iron, quinine, arsenic, and the like. Car- 
diac tonics, as digitalis, caffeine, strophanthus, and strychnia, 
are indicated. 

In sudden dilatation, use diffusible stimulants, as brandy, 
ammonia, strychnia, hypodermically. 

FATTY DEGENERATION OF THE HEART. 

Definition. — The term fatty heart is applied to (1) fatty 
infiltration, in which an abnormal amount of fat is deposited in 
and upon the heart ; and (2) to fatty degeneration, in which 
the cardiac muscle has been metamorphosed into fat. 

Fatty Infiltration. 

Etiology. — It is a part of general obesity, and hence re- 
sults from an hereditary tendency, a rich diet, and sedentary 
habits. 

10 



146 DISEASES OF THE CIRCULATORY SYSTEM. 

Pathology. — The heart may be completely imbedded in 
fat, the grooves along the larger bloodvessels being favorite 
seats of deposit. Fat is also found between the muscle fibres, 
although the latter may be perfectly normal. 

Symptoms. — Shortness of breath increased by exertion, a 
weak but regular pulse, precordial distress, a tendency to pul- 
monary congestion, with a resulting obstinate bronchitis, and 
sluggish digestion. 

Prognosis. — Favorable. 

Treatment. — A regulated diet, in which the use of fats, 
starches, and sugars is restricted. Graduated exercise. The 
Turkish bath under supervision. Heart tonics, like digitalis 
and strychnia, are sometimes indicated. 

Fatty Degeneration of the Heart. 

Etiology. — (1) It follows hypertrophy in valvular disease. 

(2) It is frequently due to atheroma of the coronary artery. 

(3) It is a common result of malnutrition from old age, wast- 
ing disease, or anemia, (4) It is associated with parenchyma- 
tous degeneration in the infectious fevers. (5) It results from 
mineral poisoning, as by arsenic, antimony, phosphorus. 

Pathology. — The muscle is pale, soft, and flabby, and 
feels greasy to the hand. Microscopic examination reveals a 
deposition of granular fat in the muscle-fibres. 

Symptoms. — When the condition is marked, it is charac- 
terized by all the symptoms of heart-failure, namely, dys- 
pnoea, asthma, cough, a weak, irregular pulse, which may be 
quite rapid or unusually slow, poor digestion, w T eak heart- 
sounds, a feeble apex-beat, dropsy, attacks of syncope, and, 
near the end, Cheyne-Stokes breathing. 

Disturbed innervation often causes palpitation, precordial 
distress, and attacks of angina pectoris. 

There may be associated evidences of atheroma, namely, 
rigid arteries, and in the cornea, a fatty a reus senilis. 

Prognosis. — Unfavorable. Death may occur suddenly on 
slight exertion. 

Treatment. — Rest of mind and body. A carefully-regu- 
lated diet, which should be light but nutritious. Iron, 



ANGINA PECTORIS. 147 

quinine, and arsenic are sometimes indicated. In this condi- 
tion strychnia (gr. ^"iro thrice daily) is often of great value. 
Nitro-glycerine (gr. t -J-q or one minim of the one per cent, 
thrice daily) may relieve the distressing symptoms. Restless- 
ness, precordial distress, and insomnia will call for morphia. 
In angina, hot applications should be applied to the prsecor- 
dia, and nitrite of amy] administered by inhalation. 

ANGINA PECTORIS. 

(Neuralgia of the Heart, Stenocardia.) 

Definition. — A paroxysmal affection characterized by 
severe pain radiating from the heart to the shoulder, thence 
down the arm ; by great anxiety, and fixation of the body, and 
apparently dependent upon some lesion of the cardiac arteries, 
walls, or valves. 

Etiology. — Male sex and middle life are generally predis- 
posing factors. Syphilis, rheumatism, gout, alcoholism, and 
Bright's disease may lead to it by inducing atheroma of the 
coronary arteries. 

The attacks may come on without provocation, but eating 
and excitement, emotional or physical, usually induce them. 
In some instances the pain appears during sleep. 

Pathology. — Atheroma of the coronary artery, fatty de- 
generation of the heart, and valvular lesions are the conditions 
usually found after death. Their relation to angina is still a 
matter of conjecture. 

In rare instances, the condition is probably a pure neurosis, 
for no lesions are found. 

Symptoms. — Severe pain radiating from the prsecordia to 
the left shoulder and thence down the arm. A sensation of 
tingling often accompanies the pain. There is great anxiety, 
a fear of approaching death, and fixation of the body. The 
face is pale or livid, and the brow bathed in sweat. Dyspnoea 
is often noted, and the pulse is variable, being usually tense and 
rapid. The duration of the attack is from a few seconds to 
several minutes. 

Diagnosis. Gastralgia. — The pain does not radiate to 
the shoulder and thence down the arm ; there is no fear of 



148 DISEASES OF THE CIRCULATORY SYSTEM. 

approaching death, and no fixation of the body ; the attack 
usually appears when the stomach is empty ; there is no evi- 
dence of organic heart disease. 

Pseudo-angina, or Hysterical Angina. — This affection occurs 
chiefly in women of a neurotic temperament ; is unassociated 
with organic heart disease ; usually occurs at night ; rarely 
induces fixation of the body ; is of longer duration than true 
angina ; and is associated with emotional excitement. 

Prognosis. — Grave. Sudden death is to be expected. 

The duration is often long, and in some instances recovery 
follows. The prognosis is more favorable when the paroxysms 
are mild, infrequent, unassociated with organic lesions, and 
brought on by exertion. 

Treatment. The Attack. — Inhalation of nitrite of amyl 
(a few drops on a handkerchief) and hot applications to the 
prsecordia. If prompt relief does not follow, give sulphate of 
morphia (gr. J) with sulphate of atropine (gr. y^oO hypoder- 
mically. 

The Interval. — Rest of body and mind. A carefully-regu- 
lated diet, which should be light but nutritious. 

Iodide of potassium (gr. x thrice daily) over a long course 
has been highly recommended. 

Nitroglycerine (gr. t ^q to ^) when well borne is some- 
times extremely useful in warding off the attacks. Patients 
may be provided with glass capsules of nitrite of amyl. 
General tonics, like strychnia, iron, and arsenic, are often indi- 
cated. 

ANEURISM OF THE AORTA. 

Definition. — A circumscribed dilatation of the aorta. 

Etiology. — The male sex, middle life, and laborious work 
are general predisposing factors. The conditions which lead 
to arterial degeneration, like syphilis, rheumatism, gout, and 
alcoholism, are potent predisposing causes. 

Sudden exertion is commonly the exciting cause. 

Pathology. — Aneurisms are divided according to shape 
into the fusiform, saccular, and cylindrical forms. When all 
the arterial tunics have yielded, the dilatation is termed a true 



ANEURISM OF THE AORTA. 149 

when the internal tunic alone has ruptured, and 
blood has escaped between the layers, it is termed a false or 
dissecting aneurism. 

A true aneurism is composed (1) of au external or adven- 
titious sac which results from inflammation and condensation 
of the surrounding connective tissue; (2) of one or more of 
the degenerated coats of the vessel ; and (3) of a clot, which is 
often firm and laminated. 

The arch of the aorta is the most common seat. About ten 
per cent, of aortic aneurisms are abdominal. 

Thoracic Aneurism. 

Physical Signs. Inspection. — This often detects an abnor- 
mal prominence and pulsation in the upper sternal region. 

Dilatation of the superficial veins may also be noted, and 
in advanced cases the skin over the prominence may be red 
and glossy. 

Palpation. — This often detects an expansile pulsation and 
a systolic thrill. 

If the cricoid cartilage is grasped between the fingers and 
thumb, and drawn upwards, a pulsation or tug may be trans- 
mitted to the trachea. 

Percussion. — This occasionally reveals circumscribed d ill- 
ness and increased resistance. 

Auscultation. — If the clot is not too large, the ear may 
detect a systolic bruit or murmur. Accentuation of the heart- 
sounds is often noted. 

Pulse. — The pulse in one radial may be delayed, and dimin- 
ished in volume from the diffusion or spending of the current 
within the sac, or from the partial occlusion of the arterial 
orifice. 

Symptoms. — Dyspnoea results from pressure upon the 
trachea, bronchi, or recurrent laryngeal nerve, the last causing 
spasm or paralysis of the vocal cords. Cough is rarely absent, 
and w*hen due to spasm of the vocal cords it is of a metallic, 
barking character. 

Pain frequently results from pressure on the bones — ver- 
tebrae and sternum, or from irritation of neighboring nerves. 



150 DISEASES OF THE CIRCULATORY SYSTEM. 

Dilatation or contraction of one pupil may result from pres- 
sure on the cervical sympathetic, and unilateral sweating of the 
face is sometimes induced by the same cause. 

Difficult swallowing (dysphagia) results from pressure on 
the oesophagus; and dilatation of the superficial veins, cyano- 
sis, and local oedema may result from pressure upon the deep- 
seated veins. 

Diagnosis. — A solid tumor may yield a transmitted pulsa- 
tion and simulate aneurism, but in the former the pulsation is 
up and down, not expansile, the impact is less pronounced, 
the bruit is usually absent, the heart-sounds are not accentu- 
ated, there is no tracheal tug, and the health is generally more 
impaired. 

Pulsating Empyema. — A left-sided purulent effusion may 
transmit a cardiac pulsation, but the latter is not expansile, 
the dulness is diffuse, the bruit is absent, and the history will 
suggest pleurisy. 

An expcunstte aorta may simulate aneurism. This condi- 
tion usually occurs in women of a neurotic temperament, and 
lacks the bruit and pressure-symptoms. 

Prognosis. — Always grave. The average duration is from 
one to two years. Death may result (1) from rupture exter- 
nally, or internally into the pericardium, heart, pleural sac, 
bronchi, lung, or oesophagus ; (2) from exhaustion ; (3) from 
heart-failure, for sometimes the aneurism dilates the aortic ori- 
fice and thereby causes aortic insufficiency. 

Treatment. — Mechanical treatment by ligation of distal 
arteries, acupuncture, and electrolysis, has not only been un- 
satisfactory, but has often shortened life. 

The treatment commonly employed is a modification of 
Tufnell's method, and consists in absolute rest in bed for from 
eight to twelve weeks, with a dry diet, and the administration 
of iodide of potassium, which is used empirically in doses of 
ten to twenty grains, thrice daily. When the pulse is very 
strong, heart sedatives like aconite and veratrum viride may 
be administered, or venesection cautiously practised. Pain is 
often temporarily relieved by the iodide, but when it is severe 
an ice-bag may be applied locally and morphia given hypoder- 
micallv. 



A ET E K 1 0-S< ) I .EROSIS . 151 

Aneurism of the Abdominal Aorta. 

Seat. — It is most frequently located near the coeliac axis. 

Symptoms. — It may be recognized by sharp pain in the 
back, radiating along the spinal nerves, and increased by eat- 
ing and d linking, by a delay in the femoral pulse, by gastro- 
intestinal symptoms, and by physical signs similar to those of 
thoracic aneurism. 

Diagnosis. — An abdominal cancer may receive a pulsation 
from the aorta, and simulate aneurism, but in the former, pul- 
sation is not expansile, and is frequently lost when the patient 
is placed in the knee-breast posture; and there is greater 
cachexia, and gastro-intestinal disturbance. 

The pulsating aorta of nervous women may simulate aneu- 
rism, but there are no pressure-symptoms, or distinct tumor, 
and it is in the sex in which abdominal aneurisms are very un- 
common. 

Prognosis. — -Very grave. Death usually results from 
rupture. 

Treatment. — Same as in thoracic aneurism. Compression 
of the aorta, the patient having been anaesthetized, has given 
good results. 

ARTERIO-SCLEROSIS. 

(Atheroma, Gull and Sutton's Disease.) 

Definition. — A thickening of the arteries due to an over- 
growth of connective tissue, associated with more or less fatty 
degeneration and calcification. 

Etiology. — Old age, gout, rheumatism, alcoholism, syph- 
ilis, lead-poisoning, nephritis, and laborious work are predis- 
posing causes. 

Pathology. — The arteries are thickened, tortuous, and 
rigid. The intima reveals roughened and opaque areas, which 
are often the seat of calcareous deposits. In extreme cas< s 
there may be spots of necrotic softening in the subendothelial 
tissue, forming " atheromatous abscesses." Microscopic ex- 
amination shows more or less fatty degeneration of the different 
coats, and an overgrowth of connective tissue in the intima. 



152 DISEASES OF THE CIRCULATORY SYSTEM. 

Symptoms. — Rigidity of the peripheral vessels ; a sluggish, 
high-tension pulse ; accentuation of the second aortic sound, 
and hypertrophy of the left ventricle. 

Sequelae. — Cerebral congestion, apoplexy, angina pectoris, 
aneurism, interstitial nephritis, gangrene of the extremities. 

Treatment. — A careful regulation of the habits, clothing, 
and diet. Stimulants must be avoided. Iodide of potassium 
(gr. v thrice daily) has been recommended for its absorbent 
effect. Nitroglycerine is sometimes valuable in overcoming 
the high arterial tension. 



DISEASES 



RESPIRATORY SYSTEM 



THE NOSE. 



The Red Nose. — A nose which is permanently and uni- 
formly red generally indicates alcoholism or acne rosacea. A 
nose which is permanently red and swollen at the extremities, 
and has a broadened bridge, indicates chronic hypertrophic 
rhinitis. 

Flattening of the Bridge. — This may result from trauma- 
tism or tertiary syphilis. 

Movement of the Alse Nasi during Respiration. — Playing 
of the alse is occasionally noted in health, but it is generally 
an indication of some obstruction to the entrance of air. It is 
frequently observed in spasmodic croup, true croup, laryngeal 
oedema, capillary bronchitis, and pneumonia. 

Nasal Discharge. — Temporary "running from the nose" is 
a symptom of acute coryza, measles, hay-fever, diphtheria, 
and influenza. An offensive discharge should suggest nasal 
diphtheria, or the impaction of a foreign body. 

Chronic discharge occurs in chronic rhinitis. In infants, 
chronic nasal discharge with mouth-breathing (" snuffles'') is 
very suggestive of hereditary syphilis. 

the Sense of Smell. — This is tested by holding odoriferous 
substances before one nostril at a time while the other is closed. 
Pungent vapors should be avoided, as the irritation which 
they excite, and not their odor, may lead to their recognition, 

( 153 j 



154 DISEASES OF THE RESPIRATORY SYSTEM. 

The sense of smell is impaired or lost (anosmia) from :-— 

1 . Rhinitis or morbid growths. 

2. Affections of the anterior part of the brain, involving 
the olfactory nerves or bulbs — as injury, tumor, meningitis. 

3. Lesions of the olfactory centres. 

4. Paralysis of the trigeminal nerve (by inducing dryness 
of the mucous membrane). 

5. Old age. 

An increase (hyperosmia) or a 'perversion (parosmia) of the 
sense of smell may occur in hysteria, insanity, and in an aura 
of epilepsy. 

Epistaxis, — Hemorrhage from the nose occurs under the 
following conditions : (1) Traumatism. (2) Inflammation. 
(3) Obstructed circulation — as in chronic heart, lung, and liver 
disease. (4) Blood-dyscrasia — as in scurvy, infectious fevers, 
haemophilia, and purpura. (5) Onset of fevers, especially 
typhoid. (6) Vicarious menstruation. (7) In rarefied atmo- 
sphere, as in mountain-climbing. (8) Often without obvious 
cause. 

THE LARYNX. 

Spasm of the laryngeal adductors is characterized by intense 
dyspnoea and occurs in spasmodic croup; in true croup; in 
ulceration of the larynx ; in laryngismus stridulus ; in whoop- 
ing-cough ; in tetany ; in hysteria ; in hydrophobia ; in the 
laryngeal crisis of locomotor ataxia ; when foreign bodies have 
lodged in the larynx ; and when aneurisms or mediastinal 
tumors press on the recurrent laryngeal nerve and irritate it. 

Aphonia or loss of voice may occur : — 

1. In severe inflammation of the larynx. 

2. From hysteria. 

3. In centric paralysis of the recurrent laryngeal nerves, as 
in bulbar palsy and in tumors of the medulla. 

4. In peripheral paralysis of the recurrent laryngeal nerve 
caused by the pressure of an aneurism, mediastinal tumor, or 
pericardial effusion. 

5. From prolonged use of the voice. 

6. From the lodgment of foreign bodies. 

7. From cicatricial stenosis of the larvnx. 



RESPIRATION. 



155 



Paralysis of the Laryngeal Muscles. 



Paralysis of all 
of the muscles. 



Complete uni- 
lateral paraly- 
sis. 



Complete par- 
alysis of the 
abductors. 

Unilateral par- 
alysis of the 
abductors. 

Complete par- 
alysis of the 
adductors. 



Causes. 
Hysteria ; bulbar pal- 
sy ; pressure upon 
both vagi or ~ 
accessories. 



spin; 



Pressure upon one re- 
current laryngeal by 
an aneurism or tu- 



Catarrhal laryngitis; 
bulbar palsy ; pres- 
sure on both vagi or 
recurrent s ; hysteria. 

Pressure on one recur- 
rent by an aneurism 
or mediastinal tumor. 

Hysteria ; laryngitis ; 
prolonged use of the 
voice. 



Symptoms. 
Aphonia, but no cough 
or dyspnoea. 



Voice weak and rough ; 
no cough or dyspnoea. 



Voice quite natural ; 
inspiratory stridor 
and dyspnoea ; no 
cough. 

Hoarseness ; fatigue 
after moderate use of 
the voice ; slight dys- 
pnoea. 

Aphonia, but no cough 
or dyspnoea. 



Laryngoscopy 
Appearance. 

The cords are midway 
between adduction 
and abduction, and 
are motionless (" cad- 
averic position"). 

One cord is moder- 
ately abducted and 
motionless ; the other 
is drawn beyond the 
median line in pho- 
nation. 

The cords are near to- 
gether, and brought 
still closer by inspi- 
ration. 

One cord is near the 
median line, and is 
motionless on inspi- 
ration. 

Cords are open and 
move naturally on 
respiration, but are 
motionless during at- 
tempted phonation. 



RESPIRATION. 



Dyspnoea. — Dyspnoea implies difficult breathing with or 
without an increase in the number of respirations. Dyspnoea 
which is so severe as to necessitate a sitting posture is termed 
orthopnoea. Dyspnoea may occur on inspiration, expiration, or 
both. 

Dyspnoea on expiration is chiefly noted in pulmonary emphy- 
sema and asthma. 

Dyspnoea on inspiration, or on both inspiration or expira- 
tion. In this form the base of the chest is retracted during 
the violent inspiratory efforts. 

Its chief causes are: (1) Obstruction in the larynx from 
spasm, paralysis, false membrane, oedema, or a foreign body. 
(2) Pressure of an' aneurism, tumor, or large glands upon the 
trachea, bronchi, or recurrent laryngeal nerve. (3) Asthma. 
(4) Diseases of the lungs, as pneumonia, emphysema, oedema, 
phthisis, abscess, and gangrene. (5) Pleural effusions. ((>") 
Cardiac disease. (7) Paralysis of the muscles of respira- 
tion. (8) Abdominal distention. (9) Anaemia. 



156 DISEASES OF THE RESPIRATORY SYSTEM. 

The number of respirations per minute. In the healthy 
male adult the number of respirations is about 18 to 20 per 
minute. In women and children, breathing is somewhat more 
rapid. The ratio between respirations and pulse-beats is 1 to 
4 or 4.5. 

Bapid respirations are noted in excitement ; in pyrexia ; in 
inflammatory diseases of the lungs ; in anaemia ; in certain affec- 
tions involving the base of the brain ; in poisoning from certain 
drugs which affect the respiratory centre ; in hysteria ; in painful 
affections of the respiratory muscles, as pleurodynia, pleurisy. 

Infrequent respirations are observed in certain diseases of 
the brain, as meningitis, tumor, apoplexy; in advanced fatty 
degeneration of the heart ; in certain forms of coma, particularly 
ursemic and diabetic; in poisoning with certain drugs, espe- 
cially opium ; in obstruction to the air-passages, as in asthma 
and in laryngeal spasm. 

Cheyne-Stokes, or tidal-wave breathing, In this type the 
respirations gradually increase in rapidity and volume until 
they reach a climax, then gradually subside and finally cease 
entirely for from five to fifty seconds, when they begin again. 
It depends on some disturbance of the respiratory centre the 
exact nature of which is still undetermined. It is usually a 
forerunner of death, but cases have been reported in which it 
has lasted several months. 

Its chief causes are : (1) Certain cerebral diseases, as apo- 
plexy, meningitis, and tumor. (2) Advanced cardiac disease, 
especially fatty degeneration. (3) Certain forms of coma, espe- 
cially that produced by uraemia, opium-poisoning, and sun- 
stroke. 

COUGH. 

Cough results from: (1) All diseases of the lungs and 
bronchi. (2) Many diseases of the larynx. (3) Foreign 
bodies in the air-passages. (4) Certain infectious diseases, 
most of which, however, are associated with catarrh, as whoop- 
ing-cough, measles, influenza. (5) Inhalation of irritating 
vapors or gases. (6) Reflex causes, such as pressure on the 
recurrent laryngeal nerve by an aneurism, and uterine and 
gastro-intestinal affections. (7) Hysteria. 



EXPECTORATION. 1 57 

Laryngeal Cough, — This cough has a hard, metallic, ringing 
intonation, and lias been termed "croupy". It is observed in 
laryngitis ; in whooping-cough ; in tuberculosis and syphilis of 
the larynx ; when a foreign body has lodged in the larynx ; 
when au aneurism or mediastinal tumor presses on the recur- 
rent laryngeal nerve, and irritates it ; and in hysteria. 

Dry Cough. — Cough without expectoration is especially ob- 
served in the beonnnintr f inflammatorv diseases of the bronchi 
and lungs ; in pleurisy ; in most chest diseases of early child- 
hood ; and in the reflex variety 

Moist, or loose COUgh occurs in bronchitis, bronchiectasis, 
convalescent pneumonia, and phthisis. 

EXPECTORATION 

Mucoid sputum is noted especially in the beginning of acute 
bronchitis ; in asthma ; in the early stage of pneumonia ; and 
in pulmonary oedema. In the last it is very frothy and watery. 

Muco-purulent Sputum. — This is observed in subacute and 
chronic catarrhal affections of the lungs and bronchi, espe- 
cially in chronic bronchitis, convalescent pneumonia, and 
phthisis. 

Purulent Sputum. — Sputum is rarely composed of pure pus. 
Expectoration almost entirely purulent is observed in bron- 
chiectasis, in phthisis with cavities, in abscess of the lung, 
and when an empyema ruptures into the lung. 

Prune-juice Sputum. — Expectoration tinged with altered 
blood so as to resemble prune-juice. It results from reten- 
tion of the blood in the lung, and is observed in advanced 
croupous pneumonia, especially low forms, in gangrene of the 
lung, and in cancer in the lung. 

Rusty Sputum. — A rusty and tenacious sputum is strongly 
indicative of croupous pneumonia. 

Sputum containhig fibrous shreds is observed in membra- 
nous croup, in diphtheria, and in fibrinous bronchitis. 

Currant-jelly sputum is indicative of cancer in the lungs. 

Fetid sputum usually results from bronchiectasis, advanced 
phthisis with cavities, gangrene of the lung, and abscess of 
the lung. 



158 DISEASES OF THE RESPIRATORY SYSTEM. 

Such sputum when allowed to stand in a conical glass set- 
tles in three layers : an upper layer of dirty froth, a middle 
layer of turbid mucus in which are suspended purulent strings, 
and a bottom layer of decomposed pus. 

Nummular Sputum. — Sputum found in round, flat, coin- 
shaped masses, which are heavy and sink in water. This 
sputum is observed in advanced phthisis, in chronic bron- 
chitis, and in bronchiectasis. 



THE MICROSCOPY OF SPUTUM. 

Elastic fibres are found in the sputum in phthisis, abscess, 
gangrene of the lungs, and in some cases of bronchiectasis. 

Fig. 10. 




Elastic Fibres. 

The Detection of Elastic Fibres. — Place the sputum which 
has collected during the night in a glass beaker, aud add to it 
an equal volume of a solution of caustic soda (20 grains to 
the ounce), and boil over a spirit-lamp, stirring it occasionally 
with a glass rod. As soon as it boils pour into a conical glass, 
and add four or five times the amount of cold distilled water. 
Allow the mixture to stand for two to three hours, and exam- 
ine the sediment ns for tube-casts. (Fenwick.). 

Spirals Of Mucin. — Tightly-coiled spirals of mucin, which 
probably represent moulds of the fine bronchioles, were first 
pointed out by Cnrschmann in the sputum of asthma. They 
have also been observed in the sputum of croupous pneumonia. 



THE MICROSCOPY OF SPUTUM. 



159 



Charcot-Leyden'S Crystals. — These are small transparent 
octahedral crystals, similar to those found in the blood of leu- 
caemia. They are observed especially in the sputum of asthma. 
They have also been noted in phthisis, iu fibrinous bron- 
chitis, and in acute bronchitis. 

Fig. 11. 




Charcot-Leyclen's Asthma Crystals. (After Eiegel.) 



Crystals Of Fatty Acids. — These occur as line needles, 
singly or in bundles, and are often sharply curved near their 
extremities. They are observed in the sputum of chronic 
bronchitis, of abscess, and of gangrene of the lungs. 

Crystals of Hsematoidill. — These occur as small yellow 
needles, rhombic plates or tufts, and are found in sputa which 
contain altered blood. They may be observed in abscess, 
gangrene, and cancer of the lungs. 

Tubercle Bacilli. — The presence of tubercle bacilli in the 
sputum is an absolute proof of tuberculosis, but a failure to 
detect them after one or two examinations is no proof against 



160 DISEASES OF THE EESPIRATOKY SYSTEM. 

phthisis. The bacillus is a fine rod, in length about half the 
diameter of a red-blood corpuscle, and often slightly bent and 
beaded. Its detection depends on its power, when stained, of 
resisting the bleaching effect of acids. To view it successfully, 
a fa oil immersion lens is required. 

Fig, 12. 




Needles of Fatty Acids. (After Striimpell.)' 

Its Detection. — The Weigert-Ehrlich method : Select with 
a clean needle a minute portion from the thick part of the spu- 
tum, spread it out in a very thin film on a cover-glass, and dry 
by holding it several inches above the flame of a spirit-lamp. 
When cool place it in the staining fluid, which is prepared as 
follows : Mix 5 c. c. of aniline oil with 100 c. c. of distilled 
water, and filter, and then add 11 c. c. of a saturated alcoholic 
solution of fuchsine. The cover-glass should remain in this 
staining fluid about half an hour (in doubtful cases, twenty- 
four hours) ; when stained, rinse in distilled water, and then 
decolorize by placing the specimen for a few seconds in a 
thirty per cent, aqueous solution of nitric acid. Wash off the 
acid with distilled water, and again stain by immersing the 
cover-glass for about a minute in an aqueous solution of methy- 
lene-blue, or in a one or two per cent, aqueous solution of Bis- 
marck-brown ; now rinse, dry, and mount in Canada balsam. 



PHYSICAL EXAMINATION OF RESPIRATORY ORGANS. 161 

PHYSICAL EXAMINATION OF THE 
RESPIRATORY ORGANS. 

Inspection. 

Inspection determines the shape of the chest, any unnatural 
prominence or depression, the amount of expansion, and any 
inequality of expansion. 

Fig. 13. 



An Outline of the Normal Chest. 



Phthisinoid Chest. — The antero-posterior diameter is short; 
the thorax is long and flat ; the ribs are oblique ; the scapulae 
are prominent ; the spaces above and below the clavicles are 
depressed ; and the angle formed by the divergence of the cos- 
tal margins from the sternum is very acute. 

Rachitic Chest. — This may resemble the former, but usually 
the sides are considerably flattened, and the sternum promi- 
nent, so that the term pigeon-breast has been applied to this 
particular form. The sternal ends of the ribs are enlarged or 
" beaded/ 7 and this characteristic has given rise to the term 
" rachitic rosary. 7 ' There is often a circular constriction of 
the thorax at the level of the xiphoid cartilage. 

Emphysematous Chest. — In advanced emphysema the 
thorax is short and round ; the antero-posterior diameter is 
often as long as the transverse diameter ; the ribs are horizon- 
tal ; the angle formed by the divergence of the costal margin 
11 



162 DISEASES OF THE RESPIRATORY SYSTEM. 

Fig. 14. 



Rachitic Chest. 



from the sternum is very obtuse or quite obliterated. The 
term u barrel-shaped chest" is applied to this configuration. 

Fig. 15. 



Emphysematous Chest. 

Local Prominences and Depressions. — An unnatural promi- 
nence or depression is often observed over the lower part of 
the sternum, and is generally congenital. The term funnel- 
breast or shoemaker's-breast (because it may result from the 
pressure of tools) has been applied to the sternal depression. 

A Unilateral or Local Depression may be due to: (1) 
Phthisical consolidation. (2) Cavity. (3) Pleurisy with 
fibrous adhesions. 

A Unilateral or Local Prominence may be due to: (1) 
Pleurisy with effusion. (2) Pneumothorax, hydrothorax, 



PHYSICAL EXAMINATION OF RESPIRATORY ORGANS. 163 

hemothorax. (3) An aneurism or tumor. (4) Compensatory 
emphysema, resulting from impairment of the opposite lung. 
(5) Cardiac enlargements (left side). (6) Enlargements of 
the abdominal organs, especially the liver and spleen. 

Expansion. — In women and in children, breathing is largely 
thoracic, or costal ; in men and in the old of both sexes, it is 
largely abdominal, or diaphragmatic. 

Restricted abdominal breathing is observed in pregnancy, in 
abdominal tumors and effusions ; in peritonitis ; in diaphrag- 
matic pleurisy ; in paralysis of the phrenic nerve from pressure 
or from bulbar disease ; and occasionally in the " hysterical 
abdomen." 

Palpation. 

Palpation serves to detect any thoracic tenderness, oedema, 
friction-fremitus, or rales, and to determine the vocal fremitus 
and amount of expansion. 

Thoracic tenderness is observed in pleurisy ; in phthisis, 
and pneumonia from being associated with pleurisy ; in pleuro- 
dynia ; in intercostal neuralgia (confined to certain spots) ; 
and in surgical affections, like caries and fracture of the ribs ; 
and in contusion and inflammation of the parietes. 

(Edema Of the Chest walls is recognized by " pitting" when 
pressure is made with the finger. It may be observed in em- 
pyema ; in deep-seated abscesses of the parietes ; after the 
application of a blister; and in general dropsy. 

Friction-fremitus and Rales.— The friction-sound of pleu- 
risy and harsh sonorous rales can sometimes be detected by 
palpation. 

Vocal, or Tactile Fremitus — The transmission of the vibra- 
tions of the voice to the hand. 

In determining the vocal fremitus observe the following pre- 
cautions : Palpate symmetrical parts of the chest ; make firm 
pressure ; when comparing use the same pressure on the two 
sides; apply the hands as nearly parallel to the ribs as 
possible ; and remember that the fremitus is normally in- 
creased over the right apex. 



164 DISEASES OF THE RESPIRATORY SYSTEM. 

Vocal fremitus is increased in : (1) Phthisical consolidation. 
(2) Pneumonic consolidation. 

Vocal fremitus is decreased in: (1) Pleural effusions — air, 
pus, serum, lymph, or blood. (2) Emphysema. (3) Pulmo- 
nary collapse from an obstructed bronchus. (4) Pulmonary 
oedema. (5) Morbid growths of the lung. 

Percussion. 

Percussion determines resonance, pitch, and resistance. 

Immediate percussion is performed by striking the chest di- 
rectly with the fingers. It is not often employed, except over 
the clavicles, where the bones themselves act as pleximeters. 

Mediate percussion is performed by using the fingers of one 
hand as a plessor, and those of the opposite hand as a plexi- 
meter ; or by using a piece of ivory, glass, or hard rubber as a 
pleximeter, and a small hammer as a plessor. 

The use of the fingers alone is preferable, for only in this 
way can resistance be determined. 

In percussion the following precautions should be observed : 
Place the finger which is being used as a pleximeter firmly 
against the chest, and preferably parallel to the ribs ; make 
the finger which is used as plessor strike the one on the chest 
perpendicularly ; fix the forearm, and use no more force than 
can be obtained from a gentle swing of the wrist. When pos- 
sible, percuss all parts of the chest anteriorly and posteriorly ; 
percuss both in inspiration and in expiration. In comparing 
the two sides, be sure to percuss symmetrical parts. 

Normal Resonance. — On the right side, pulmonary resonance 
extends from a half inch to an inch above the clavicle, down- 
ward to the upper border of the sixth rib in front, and to a line 
drawn through the tenth spinous process posteriorly. 

On the left side, pulmonary resonance extends from a half 
inch to an inch above the clavicle, downward, within the mam- 
mary line to the third rib, outside of the mammary line to the 
tenth rib, and posteriorly to a line drawn through the tenth 
spinous process. 

Hyper-resonance is observed in the following conditions : 
(1) Pneumothorax. (2) Cavities — tuberculous or bronchiec- 
tatic. (3) Emphysema. (4) Lowered pulmonary tension in 



AUSCULTATION. 165 

the initial stage of pneumonia and above a pleural effusion 
(Skoda's resonance). (5) Flatulent distention of the stomach 
or colon (frequently observed over the left base). 

A tympanitic note is a hollow, drum-like sound like that 
which is normally obtained by percussing the larynx or empty 
stomach. The above conditions are also capable of producing 
tympany. 

The cracked-pot SOnnd, or bruit de pot file, is a modified 
tympany, and can be simulated by percussing over the cheek 
when the mouth is partially open. It may be normally heard 
over the chest of a crying infant (Walshe). In the adult it 
usually indicates a cavity which has a free communication 
with a bronchus. It is best detected by keeping the ear near 
the open mouth of the patient while percussing. 

DulneSS or flatness is recognized in the following condi- 
tions : (1) Phthisical consolidation. (2) Pneumonic consoli- 
dation. (3) Pleural effusions of all kinds, except air. (4) Col- 
lapse of the lung. (5) Congestion and oedema of the lung. 
(6) Enlargement of the liver or spleen (at the bases). (7) 
Morbid growths in the lung. 

Pitch. — Pitch depends largely upon the volume of air, upon 
the tension of the walls of the cavity, and upon the size of the 
opening which communicates with the cavity. The less the air, 
the greater the tension, and the smaller the opening, the higher 
will be the pitch of the note. It is obvious, therefore, that 
conditions which are associated with hyper-resonance may 
yield either a high- or a low-pitched note. In beginning 
phthisical consolidation, the note over the affected apex is 
higher pitched ; but it must be borne in mind that normally 
the note over the right apex is higher pitched than that over 
the left. 

Resistance. — The greater the dulness the greater will be the 
resistance ; hence there is always more resistance over a large 
pleural effusion than over a pneumonic or phthisical con- 
solidation. 

Auscultation. 

Auscultation determines the character of the breathing and 
of the vocal resonance, and detects adventitious sounds, like rales. 



166 DISEASES OF THE RESPIRATORY SYSTEM. 

In immediate auscultation the ear is placed directly over the 
chest, a soft towel only intervening. 

In mediate auscultation the sounds are transmitted through 
a stethoscope, which should be applied to the bare chest. 

In auscultation observe the following precautions : Do not 
exert much pressure with the stethoscope ; when the chest is 
covered with hair moisten the latter, otherwise it will produce 
friction-sounds resembling rales. When possible, auscult all 
over the chest, anteriorly and posteriorly ; auscult on quiet 
breathing, on full inspiration, on full expiration, and after 
coughing. In comparing the two sides auscult symmetrical 
parts. 

Normal Respiration. — Vesicular breathing is heard over the 
body of the lungs, and is characterized by a soft, breezy inspi- 
ration and a short, low-pitched expiration. Normally, expi- 
ration is not more than one-third as long as inspiration. Aus- 
cultation over the trachea, or over the main bronchi in the 
interscapular space, yields bronchial breathing, i. e., harsh 
breathing with prolonged high-pitched expiration. 

Modifications of the respiratory murmur. Puerile Breath- 
i n q, — This type is heard normally over the lungi of children ; 
it is loud, and expiration is higher pitched than in vesicular 
breathing, and almost as long as inspiration. 

Exaggerated Breathing. — This type has almost the same 
peculiarities as puerile breathing, and is heard over a lung 
that is doing extra work necessitated by some impairment of 
its fellow. 

Bronchial or Tubular Breathing. — Harsh breathing, with 
a prolonged high-pitched expiration, which has sometimes a 
tubular quality. Bronchial breathing is heard over : (1) 
Phthisical consolidation. (2) Pneumonic consolidation. (3) 
Lung which is compressed. (4) Lung which is infiltrated 
with a morbid growth. 

Amphoric and Cavernous Breathing. — These two are almost 
identical; the sounds are loud, and expiration is prolonged and 
hollow. The pitch of amphoric breathing is a little higher 
than that of cavernous. Amphoric breathing may be imitated 
by blowing over the mouth of an empty jar. 

Amphoric or cavernous breathing may be heard in the fol- 



AUSCULTATION. 167 

lowing conditions : (1) Phthisical or bronchiectatic cavities. 

(2) Pneumothorax, when the opening in the lung is patulous. 

(3) Areas of consolidation near a large bronchus. (4) Some- 
times over lung compressed by a moderate effusion. 

Asthmatic Breathing. — Harsh breathing with a prolonged 
wheezing expiration. It may resemble bronchial breathing, 
but, unlike the latter, it is heard all over the chest. 

The Breathing of Emphysema. — Weak breathing, with pro- 
longed low-pitched or inaudible expiration. 

Cogged-wheel, or Jerky Breathing. — The respiratory murmur 
is not continuous, but is broken into waves. It is not indicative 
of any special disease, but it is frequently observed in bron- 
chitis and in incipient phthisis. 

Weak or Shallow Breathing. — This is noted : (1) When the 
chest-walls are thick. (2) In the old and feeble. (3) In 
emphysema. (4) In pleural effusion. (5) In incipient 
phthisis. (6) In painful affections of the chest, like pleuro- 
dynia and beginning pleurisy. (7) In pulmonary cedema. 

Vocal Resonance. — The vibrations of the voice transmitted 
to the ear. 

Vocal resonance is normally increased over the right apex. 
It is abnormally increased in : (1) Pneumonic consolidation. 

(2) Phthisical consolidation. (3) Cavities which freely com- 
municate with a bronchus. 

Vocal resonance is diminished or absent in: (1) Pleural 
effusions — air, pus, serum, lymph, or blood. (2) Emphysema. 

(3) Pulmonary collapse. (4) Pulmonary oedema. 
Bronchophony. — Extreme exaggeration of the vocal resonance ; 

the sounds, but not the words, are transmitted. It is especially 
noted over marked consolidations and over certain cavities. 

Pectoriloquy. — The distinct transmission of whispered words 
to the ear ; the sounds appear to emanate from the spot which 
is ausculted. 

Pectoriloquy is heard over : (1) Cavities which communicate 
with a bronchus. (2) Areas of consolidation in the neighbor- 
hood of a large bronchus. (3) Pneumothorax, when the open- 
ing in the lung is patulous. (4) Some pleural effusions. 

JEgo-phony. — A modified bronchophony, characterized by a 
trembling, bleating sound. It is usually heard over slight 



168 DISEASES OF THE RESPIRATORY SYSTEM. 

pleural effusions near the upper border of dullness, especially 
near the inferior angle of the scapula. 

It is occasionally heard in beginning pneumonia. 

Adventitious Sounds. Rales, or Rhonch i. — These are abnor- 
mal sounds which replace or accompany the respiratory murmur. 

C Vesicular = Crepitant. 

Pulmonary rales \ Sonorous. 

u u- i f Y I Sibilant. 
I bronchial J ^ Subcrepitant. 

v Moist < Bubbling. 
(Gurgling. 
Extra-pulmonary rales = Pleuritic friction-sounds. 

Crepitant Rales. — These are very fine rales, and are heard at 
the end of inspiration. They may be simulated by rubbing a 
lock of hair between the fingers. They have been especially 
associated with the first stage of croupous pneumonia, and it 
has been supposed that they were due to the forcible separation 
of adherent vesicular walls. Rales very similar to, if not iden- 
tical with these, are heard in capillary bronchitis and in pul- 
monary oedema. 

Dry rales are probably produced by the presence of viscid 
secretion in the tubes; they have a more or less whistling, 
musical, or squeaking intonation. They are heard particularly 
in bronchitis and asthma. Sibilant rales are whistling and 
high pitched ; sonorous rales have a humming quality and are 
lower pitched. Dry rales may be heard on inspiration, expi- 
ration, or both. 

Moist redes result from the presence of liquid in the tubes ; 
the thinner the liquid and the larger the tube, the coarser will 
be the rales. They may be heard on inspiration, expiration, 
or both. 

Subcrepitant, or crackling rales are fine moist rales, and heard 
in all conditions which are associated with liquid in the smaller 
tubes, as bronchitis, capillary bronchitis, pulmonary oedema, 
and beginning phthisis. 

Bubbling redes are coarser than subcrepitant ; and are heard 
in bronchitis, in resolving croupous pneumonia, over phthisical 
deposits which are softening, and over small cavities. 



AUSCULTATION. 169 

Gurgling rales are very coarse and resemble the bursting of 
large bubbles. They are heard over large cavities which con- 
tain fluid, and in the trachea in the so-called " death-rattle." 

Friction- sounds are produced by the rubbing together of 
roughened pleural surfaces. They may be heard both in in- 
spiration and expiration, and often resemble subcrepitant rales, 
but they are more superficial and localized than the latter, and 
are not modified by cough or deep inspiration. 

A roughened pleura in the neighborhood of the heart may 
produce a friction-sound of cardiac rhythm, and one which 
will still continue when the breath is held; under other condi- 
tions pleural friction-sounds cease when respiration is sus- 
pended. 

Other Adventitious Sounds. Metallic Tinkling. — This name 
is applied to silvery or bell-like sounds which are heard at in- 
tervals over a pneimio-hydrothorax or large cavity. Speaking, 
coughing, and deep breathing usually induce them. Care 
must be taken not to confound them with similar sounds pro- 
duced by the presence of liquid in a distended stomach. 

Succussion-splath, or Hippocratie Suceussion. — This is a 
splashing sound produced by the presence of air and liquid in 
the chest. It may be elicited by gently shaking the patient 
while auscultating. It nearly always indicates either a hydro- 
or a pyo-pneumothorax, although it has been detected over 
very large cavities. 

Air and liquid in the stomach produce a similar sound. 

Mensuration. 

In measuring the sides of the chest observe the following 
precaution : Measure from the middle of the sternum to the 
spinous processes ; measure both sides after inspiration and 
after expiration ; apply the tape with equal firmness to the two 
sides. In comparing, measure corresponding levels, and re- 
member that the right side is from half an inch to an inch 
greater in circumference than the left. 

The conditions which render one side more prominent than 
the other have already been considered. 



170 DISEASES OF THE RESPIRATORY SYSTEM. 



CORYZA. 

(Acute Rhinitis, Cold in the Head.) 

Definition. — An acute inflammation of the nasal cavities. 

Etiology. — Exposure to cold drafts aud to wet, especially 
when the body is overheated, is a common cause. It may be 
excited by the inhalation of irritating vapors or dust. It is 
an expression of iodism. It is a symptom of certain infectious 
diseases — especially syphilis, measles, and influenza. 

Pathology. — The mucous membrane is red and swollen. 
In the first stage there is no secretion, but later irritating, 
watery mucus flows from the nose and excoriates the lip ; this 
in time is followed by a copious muco-purulent discharge. 

Symptoms. — The disease is ushered in with chilliness, 
malaise, fulness in the head, and sneezing. The nasal cham- 
bers are obstructed, so that the patient is obliged to breathe 
through his mouth. At first there is no secretion, but in 
twenty-four or forty-eight hours a watery discharge is estab- 
lished, which later becomes muco-purulent. Slight fever and 
its associated symptoms are commonly present. The duration 
is from a few clays to two weeks. 

Complications. — The disease is often accompanied with 
conjunctivitis, pharyngitis, laryngitis, and catarrh of the 
Eustachian tube and middle ear which results in temporary 
deafness. 

Prognosis. — Favorable. 

Treatment. — In the early stage a cold in the head can 
frequently be aborted by the use of hot drinks, a laxative, 
moderate doses of quinine, and the application of menthol to 
the nasal chambers. Some crystals of menthol may be placed 
in a wide-mouth bottle, and their vapor inhaled for from ten 
to twenty minutes several times during the day. A spray of 
menthol may be employed : — 

J$_ Menthol, 3J ; 

Ol. amygd.' dulcis, vel benzoinal, f^ij — M. 
Sig. — Spray into the nose several times daily. 



CHRONIC NASAL CATARRH. 171 

Cocaine is often efficient in allaying the fulness and distress; 
a four per cent, solution may be applied to the nose on a 
pledget of cotton or by means of a camel's-hair brush. 

When the symptoms are severe Dover's powder (gr. v) may 
be given in combination with quinine (gr. v) thrice daily. 

CHRONIC NASAL, CATARRH. 

(Chronic Rhinitis.) 

Definition. — A chronic inflammation of the nasal mucous 
membrane, characterized by increased secretion and impair- 
ment of the sense of smell. 

Etiology. — Repeated attacks of acute coryza, impure air, 
the continual inhalation of irritating dusts or vapors, lowered 
vitality, and congenital or acquired obstruction of the nasal 
chambers are causal factors. It is also an expression of 
syphilis. 

Varieties. — Two varieties have been recognized : Chronic 
hypertrophic rhinitis and chronic atrophic rhinitis. 

* Hypertrophic Rhinitis, Symptoms. — A thick mucous dis- 
charge from the nose; great liability to attacks of acute 
coryza ; obstruction of one or both nasal cavities, causing 
mouth-breathing ; a nasal intonation of the voice ; frontal 
headache ; and impairment of the sense of smell. 

Symptoms of catarrh of the neighboring organs are fre- 
quently present. The most common of these are : dryness of 
the throat and hawking from pharyngitis ; deafness from 
catarrh of the middle ear ; and watering of the eyes from catar- 
rhal occlusion tf the lachrymal canal. 

Inspection. — The bridge of the nose is frequently flattened, 
and the alee are thickened and red ; the mucous membrane is 
red and the cavities are more or less occluded from hyper- 
trophy of the cavernous tissue covering the turbinated bones. 
In advanced cases exostoses from the bony framework are 
sometimes noted. 

Prognosis. — Under judicious and persistent treatment the 
affection is curable. 

Treatment. — The naso-pharynx must be kept clean by 



172 DISEASES OF THE EESPIEATORY SYSTEM. 

means of antiseptic douches or sprays ; one of the following 
may be employed : — 

]£. Acid, carbol. liq., Vf[ xxx ; 
Sodii biborat., 
Sodii bicarb., aa 3j ; 
Grlycerinse, f^iijss ; 
Aquae, q. s. ad f^iv. — M. 



Or— 



J$l Listerine, 

Aqua?, aa f^ij— M. 



Mild astringent sprays are often useful, and sulphate of 
zinc or sulphate of copper (five to ten grains to the ounce) may 
be employed for this purpose. 

Tonics like cod-liver oil, hypophosphites, iron, arsenic, and 
strychnia are often indicated. 

To effect a cure the naso-pharynx must be unobstructed ; 
hypertrophies and exostoses must be removed and deviations 
of the septum corrected by surgical means. 

Atrophic Rhinitis. (Ozcena) Symptoms. — A sense of dry- 
ness in the nose and throat ; a thick purulent discharge, or the 
expulsion of discolored crusts : an offensive, putrid odor, which 
has given rise to the term of Qzcma; impairment of the sense 
of smell. The general health is always poor; such patients 
are usually thin and anaemic. 

Inspection. — The chambers are large; the mucous membrane 
is pale, dry, and glazed ; adherent scabs are generally present. 
In advanced cases, ulceration and necrosis are observed. 

Prognosis. — Perfect cure is rarely obtainable ; but treat- 
ment may effect great improvement. 

Treatment. — Crusts must be removed and the nasal 
chambers kept clean with antiseptic sprays or douches. Stim- 
ulating applications are useful . and solutions of nitrate of 
silver, sulphate of iron, or sulphate of zinc may be employed. 
General tonics like cod-liver oil, hypophosphites, iron, arsenic, 
etc. are indicated. 



ACUTE CATARRHAL LARYNGITIS. 173 



ACUTE CATARRHAL LARYNGITIS. 

Definition. — An acute catarrhal inflammation of the 
larynx, characterized by hoarseness, hard cough, and painful 
deglutition. 

Etiology. — Improper use of the voice ; exposure to cold 
and wet ; the inhalation of irritating dusts or vapors; the im- 
paction of foreign bodies are its common causes. It is also an 
associated condition in certain infectious diseases, like whoop- 
ing-cough, measles, diphtheria, and influenza. 

Pathology. — The mucous membrane is red, swollen, and 
injected. 

In grave cases the tissues may be markedly oedematous. 

Symptoms. — Hoarseness of the voice or aphonia ; hard, 
ringing cough ; pain in the throat increased by speaking, 
coughing, and swallowing ; expectoration, which is first scanty 
and later muco-purulent ; fever and its associated symptoms. 
In sensitive people, and especially in children, paroxysms of 
croupy cough and dyspnoea (false croup) may result from 
spasm of the vocal cords ; and when there is much oedema, 
dyspnoea or asphyxia will be a prominent feature. 

Inspection. — The mucous membrane of the laryngeal walls 
and vocal cords is red and swollen. In grave cases the tissues 
are highly oedematous. 

Prognosis. — In simple laryngitis without oedema the prog- 
nosis is altogether favorable. The attack usually lasts from 
a week to ten days. When there is oedema of the larynx, 
indicated by dyspnoea or asphyxia, the prognosis is grave. 

Treatment. — The patient should be confined to his room 
and preferably to bed. The temperature of the room should 
be 70° or 75°, and the atmosphere should be moistened by the 
generation of steam. 

Iodine, or in severe cases an ice-bladder, should be applied 
to the throat. The inhalation of medicated vapors is decidedly 
useful, and one of the following may be employed : Lime- 
water, Dobell's solution, wine of ipecac (diluted with two 
volumes of water), or the menthol mixture mentioned in the 
treatment of acute coryza. 



174 DISEASES OF THE RESPIRATORY SYSTEM. 

Internal Treatment. — A saline laxative may be administered 
at th'e beginning, and followed by one of the following seda- 
tive mixtures : Dover's powder (gr. v) with quinine (gr. v) 
thrice daily, or : — 

]£. Potassii citratis, 

Potassii bromid., aa ,5ij ; 
Apomorph. hydrochlor., gr. ^; 
Aquae et syr. sarsaparillaB comp., aa f^iss— M. 
Sig. — A teaspoonful every two hours to a child of five }^ears. 

Or — One of the following tablets devised by Dr. Seiler : — 

J$l Potass, chlor., 

Potass, bromid., 

Pulv. ext. giyeyrrhizee, aa 3J ; 

Tinct. ferri chlor., f^ss ; 

Sacchar., etc., q. s. — M. 
Ft. in trochisci No xx. 
Sig. — One every three or four hours. 

CEdema of the larynx, indicated by extreme dyspnoea, will 
require scarification of the mucous membrane or tracheotomy. 



CHROXIC LARYNGITIS. 

Simple Chronic Catarrhal Laryngitis. Symptoms. — Tick- 
ling in the throat, huskiness of the voice, fatigue and pain 
after moderate use of the voice, and the expectoration of viscid 
mucus are the usual symptoms. 

Laryngoscopic examination reveals redness of the mucous 
membrane and sometimes slight ulcerations. 

Treatment. — The patient must learn to use the voice 
properly ; sounds must be expelled by the abdominal muscles 
and diaphragm, and not by the muscles of the throat. Flan- 
nel protectors should be avoided, and the application of cool 
water to the neck, night and morning, instituted in their stead. 
Tonics are generally indicated. Expectorants which are elim- 
inated by the respiratory mucous membrane are useful ; and 
one of the following may be employed : Terebene (gtt. v on 
sugar); oleoresin of cubebs (gtt. x-xx on sugar), oil of euca- 
lyptus (gtt. v in capsule). 



CHRONIC LARYNGITIS. 175 

Topical Treatment. — A faradic current to the neck is often 
beneficial; medicated solutions should be applied. to the larynx 
by means of a brush or atomizer. The following are the 
remedies commonly employed : Nitrate of silver, chloride of 
ammonium, chlorate of potassium, sulphate of zinc, and tinc- 
ture of benzoin. 

Tuberculous Laryngitis, — This is nearly always secondary 
to pulmonary tuberculosis, but it occasionally occurs as a pri- 
mary affection. 

Symptoms. — Hoarseness of the voice or aphonia ; pain in 
the throat increased by coughing, speaking, or swallowing ; 
and hacking cough are the usual symptoms. 

Laryngoscopic Examination. — The mucous membrane is 
pale and thickened ; the arytenoid cartilages are considerably 
swollen ; small, irregular, shallow ulcers with gray bases are 
frequently noted, particularly in the inter-arytenoid space. 

Treatment. — Bemedies must be directed to the primary 
pulmonary disease. Local applications are required to relieve 
the pain. Powders of iodoform or morphia may be dusted on 
the ulcers, or a solution of nitrate of silver, of cocaine, or of 
menthol may be applied by means of a laryngeal brush. 

Syphilitic laryngitis may manifest itself in catarrhal in- 
flammation, or mucous patches, but the most common expres- 
sion is a gummatous infiltration, which breaks down, ulcerates 
the cartilages, and ultimately leads to cicatrization and de- 
formity. 

Symptoms. — Hoarseness of the voice, hacking cough, and 
some difficulty in deglutition. Subjective symptoms are often 
absent, though examination may reveal extensive lesions. 

Laryngoscopic Examination. — Deep ulcers with raised edges, 
often symmetrically arranged. Necrosis of the cartilages re- 
sults in advanced cases. 

Diagnosis. — The history, the presence of other syphilitic 
lesions, the deep symmetrical ulcers, the effect of treatment, 
and the absence of marked pain and of pulmonary lesions will 
serve to distinguish it from tuberculous laryngitis. 

Treatment. — The system should be rapidly brought under 
the influence of antisyphilitic remedies ; for this purpose mer- 



17(5 DISEASES OF THE RESPIRATORY SYSTEM. 

curial inunctions may be employed, and iodides and mercurials 
given internally : — 

J$l Hydrarg. chlor. corros., gr. j ; 
Potass, iodidi, gij-Siv ; 
Syr. sarsaparillse comp., f^jss ; 
Aquas, q. s. ad f^iij.— M. 
Sig. — A teaspoonful twice daily after meals. 

Local applications, carefully applied by the aid of the laryn- 
goscopy mirror, are also required. Iodoform, or acid nitrate 
of mercury (1 to 5 of water), may be selected for this purpose. 

When the laryngeal movements interfere with healing, 
tracheotomy should be performed. The same operation or 
mechanical dilatation is sometimes required for the resulting 
cicatricial stenosis. 

SPASMODIC CROUP. 

(False Croup.) 

Definition. — Spasm of the vocal cords, excited by catarrh 
of the larynx. 

Etiology. — The attacks usually occur in young children, 
and are induced by the causes of catarrhal laryngitis. 

Symptoms. — Generally there has been a little hoarseness 
and cough during the day, and at night the child is awakened 
from sleep by a severe paroxysm of suffocative cough. The 
latter has a peculiar, hard, metallic quality, and is associated 
with the evidences of dyspnoea, namely : Anxious face, dilating 
nostrils, prominent sterno-cleido-mastoids, and retraction of 
the base of the chest with each inspiratory effort. During the 
paroxysm the skin is hot and the pulse is tense and rapid. In 
from a few moments to an hour the cough ceases, free perspi- 
ration follows, and the child falls to sleep. 

Two or three similar attacks may occur in the same night, 
but on the following day the child appears quite well. A 
recurrence of the seizures for several successive nights is not 
infrequent. 

Diagnosis. Laryngismus Stridulus. — This is a pure neu- 
rosis, and is often associated with the rachitic diathesis. The 
paroxysms resemble those of false croup, but are associated 



MEMBRANOUS CROUP. 177 

with a peculiar crowing inspiration, and lack catarrhal symp- 
toms, such as hoarseness and cough. 

Prog.n osjs. — Always favorable. 

Treatment. — A sponge moistened with hot water may be 
applied to the throat, or the child may be placed in a hot bath. 
If these simple measures fail, an emetic will almost invariably 
bring relief. Wine of ipecac (3j) or turpeth mineral (gr. iij-v) 
may be selected. Subsequent treatment should be directed to 
the laryngeal catarrh. 

MEMBRANOUS CROUP. 

(Croupous Laryngitis, True Croup, Pseudo-membranous 
Laryngitis.) 

Definition. — Anon-infectious inflammatory disease of the 
larynx, characterized anatomically by the formation of false 
membrane, and clinically by hoarseness, barking cough, and 
dyspnoea of gradual development. 

Etiology. — The formation of false membrane in the larynx 
usually results from diphtheria ; but a membranous inflamma- 
tion, non-infectious, is sometimes observed. Early childhood 
(between two and five years) and exposure to cold and wet 
are the predisposing causes. 

A membranous laryngitis may also result from the direct 
action of strong acids or alkalies, scalding water, or steam. 

Pathology. — The larynx is lined with a grayish-white 
pseudo-membrane which is more or less adherent. The fauces 
are rarely involved, but the membrane occasionally extends to 
the trachea. The escape of the fauces is a point of difference 
between membranous croup and diphtheria, for in the latter 
the fauces are usually primarily involved. The membrane is 
quite superficial, and rarely involves the submucous tissue. 

Under the microscope a fibrillar network is found, in the 
meshes of which are leucocytes and epithelial cells. 

Symptoms. — The disease usually begins with the symptoms 
of catarrhal laryngitis, namely, hoarseness, barking cough, and 
slight fever. Soon paroxysms of spasmodic croup appear, and 
in the intervals dyspnoea gradually develops. The res pi ra- 
tions are rapid and noisy, and are often associated with a 
12 



178 DISEASES OF THE RESPIRATORY SYSTEM. 

whistling, stridulous inspiration. There is moderate fever. 
With the increasing dyspnoea, the child grows extremely rest- 
less ; the head is forcibly extended ; the alse of the nose play ; 
the sterno-cleido-mastoids stand out prominently; and the 
base of the chest retracts with each violent inspiratory effort. 
In the paroxysms of coughing, a piece of false membrane may 
be detached and expectorated. Hoarseness soon gives place to 
aphonia ; and the cough, at first harsh, gradually becomes in- 
audible. Finally, the lips become blue ; the pulse weakens ; 
the temperature falls ; and the respirations become inaudible. 
Death is often preceded by stupor and convulsions. 

Diagnosis. Spasmodic Croup. — The dyspnoea is parox- 
ysmal ; the attacks usually appear at night, and often in the 
midst of apparent health ; and no false membrane is expecto- 
rated. In true croup the dyspnoea develops gradually and 
becomes extreme, and false membrane may be expectorated. 

Laryngeal Diphtheria. — The detection of false membrane in 
the fauces, a history of contagion, grave systemic symptoms, 
albuminuria, and such complications as paralysis, endocarditis, 
and nephritis would indicate diphtheria. 

Laryngismus Stridulus. — This is a nervous affection, charac- 
terized by paroxysms of dyspnoea accompanied by a peculiar 
crowing inspiration. The attacks occur periodically in the 
midst of apparent health, and lack fever and catarrhal symp- 
toms. 

Prognosis. — Unfavorable ; from sixty to eighty per cent, 
perish within a week or ten days. The more local the dis- 
ease, the older the patient, and the more vigorous he is, the 
better the prognosis. A return of voice anol audible breath- 
ing, a loose cough, and purulent expectoration are favorable 
indications ; but increasing rapidity and weakness of the 
pulse, cyanosis, and debility indicate a fatal issue. 

Treatment. — The temperature of the room should be kept 
at 70°, and the atmosphere should be moistened by the gene- 
ration of steam. A steam atomizer may be employed, or lime 
may be slacked in the room. Medicated sprays are sometimes 
recommended ; some turpentine or oil of eucalyptus may be 
added to the water in the receiver of the atomizer, or may be 
placed on the surface of water which is kept boiling over a 



LARYNGISMUS STRIDULUS. 171) 

stove or spirit-lamp. Hot fomentations or an ice-bladder may 
be applied to the neck. 

The best internal solvent at our command is mercury. A 
fiftieth of a grain of the bichloride may be given, well diluted, 
every hour or two to a child a year old, or a quarter of a grain 
of calomel may be given every hour to a child of the same age, 
and if it excites diarrhoea, a little paregoric may be administered 
with each dose. 

J$l Hydrarg. chlor. corros. , gr. ^ ; 
Ammon. chlor., gr. xij ; 
Aqua?, f^iij. — M. 
Sig. — A teaspoonful diluted with a dessertspoonful of water every 
hour to a child a year old. 

Quinine (gr. iij in suppository) may be employed three or 
four times daily. 

Stimulants are frequently indicated. An emetic may assist 
in the expulsion of loose membrane. Turpeth mineral (gr. 
iij— v), alum, or ipecac may be selected. 

Topical Medication. — In the very young it may be impos- 
sible to bring medicated sprays in contact with the affected 
parts, but when it is feasible much benefit accrues from this 
method of treatment. Among the solutions recommended 
may be mentioned, lime-water, DobelFs solution, lactic acid 
(1 to 10 or 20), and peroxide of hydrogen ; a fifty per cent, 
solution of the last is often very efficient. 

When these remedies fail, and the dyspnoea and cyanosis in- 
crease, and the pulse grows rapid and irregular, intubation or 
tracheotomy must be performed. The results of intubation 
are somewhat more encouraging than those of tracheotomy. 
Between thirty and forty per cent, recover after these opera- 
tions. 



LARYNGISMUS STRIDULUS. 

(Spasm of the Glottis, "Child-crowing.") 

Definition. — A paroxysmal neurosis, characterized by 
spasm of the adductors of the larynx, and not excited by any 
local inflammation. 



ISO DISEASES OF THE RESPIRATORY SYSTEM. 

Etiology. — Early life (within the first two years), male 
sex, and the rachitic diathesis are the predisposing causes. 
The discharge of motor force apparently arises in the medulla 
(bulbar epilepsy), and may be excited by reflex irritation, as 
in teething and gastro-intestinal disorders. 

Symptoms. — The attacks often occur on waking from sleep, 
and are characterized by a sudden arrest of breathing and 
tonic muscular spasms. The face is pale, and later cyanosed ; 
the eyes are rolled up ; the body is arched ; the thumbs are 
turned into the palms ; the legs are extended, and the soles 
turned inward. In a few seconds the spasm relaxes, and air 
is drawn through the glottis with a shrill, crowing sound. 

The seizures vary greatly in frequency ; several may occur 
in a day, or they may be weeks apart. 

Diagnosis. — The intermittent character of the affection ; 
the peculiar crowing inspiration ; the absence of fever, cough, 
and hoarseness will serve to distinguish laryngismus from croup. 

Prognosis. — Favorable. In the very young death may 
result from suffocation. 

Treatment. The Paroxysm. — Cold water may be dashed 
on the face and head, or a few drops of nitrite of amyl or 
chloroform may be placed on a handkerchief and held before 
the nose. 

The Interval. — Careful search should be made for some 
exciting cause ; the gums may require lancing, or the gastro- 
intestinal tract may demand attention. The child should be 
placed under the best hygienic conditions. The food should 
be plain and nutritious ; tonics, like cod-liver oil, malt, hypo- 
phosphites, and arsenic, are generally indicated. The bromide 
of potassium is an efficient antispasmodic, and may be advan- 
tageously combined with antipyrin : — - 

fy Antipyrin, gr. xij ; 

Potass, bromid., ^iss-^ij ; 
Syr. aurant. cort., f^ij ; 
Aquae, q,s. ad fjfiij.— M. 
Sig. — A teaspoonful thrice daily. 



(EDEMA OF THE LARYNX. 181 

OEDEMA OF THE LARYNX. 

(CEdema of the Glottis.) 

Definition. — An infiltration of serous fluid into the sub- 
mucous tissue of the larynx. 

Etiology. — It occasionally results from severe attacks of 
catarrhal laryngitis. It may be induced by severe inflamma- 
tion of neighboring organs — as the tonsils, parotid glands, 
and pharynx. It may be a complication of some acute infec- 
tious disease — like diphtheria, scarlet fever, or facial erysipelas. 
It is sometimes associated with ulcerative affections of the 
larynx, like tuberculosis and syphilis. It may be excited by 
the irritation of burns, scalds, or caustics. It occasionally 
occurs abruptly in the course of Bright's disease. 

Pathology. — The connective tissue of the larynx is infil- 
trated with a serous or sero-purulent fluid. The mucous mem- 
brane is tense and changed in color. 

Symptoms. — Hoarseness of the voice, and later aphonia ; 
extreme dyspnoea, at first on inspiration but later on expiration 
also ; stridulous respiration ; barking cough ; and the evi- 
dences of dyspnoea, namely : Anxious face, protruding eyes, 
blue lips, prominent sterno-cleido-mastoids, and retraction of 
the base of the chest. When the epiglottis is involved the 
swelling can be detected by the finger on the throat. 

Laryngoscopy Examination.- — The mucous membrane is 
swollen and of a reddish-purple color. The epiglottis may 
resemble a round translucent tumor. In infraglottic oedema 
the upper part of the larynx may appear normal, but swollen 
and oedematous membrane is seen projecting through the 
glottis. The vocal cords are rarely affected. 

Prognosis. — Extremely grave. 

Treatment. — When the symptoms are not urgent, leeches 
or blisters may be applied over the larynx, and astringent solu- 
tions (tannic acid or alum) sprayed on the oedematous tissues. 
When the symptoms persist, the parts should be scarified, and 
if this fails to relieve the dyspnoea, tracheotomy should be 
performed. 



182 DISEASES OF THE RESPIRATORY SYSTEM. 

BRONCHITIS. 

Definition. — An inflammation of the bronchial tubes, 
characterized by substernal soreness, cough, mucopurulent 
expectoration, and dry and moist rales. 

Varieties. — (1) Acute catarrhal bronchitis. (2) Chronic 
bronchitis. (3) Capillary bronchitis. (4) Fibrinous bron- 
chitis. 

Acute Catarrhal Bronchitis 

Etiology. — A cold, damp climate ; changeable weather ; 
occupations which necessitate confinement, or the inhalation of 
irritating dusts or vapors ; debility ; the gouty diathesis ; and 
chronic heart disease are general predisposing factors. 

Exposure to cold and wet, particularly when the body is 
overheated, or the inhalation of irritating gases or dusts is the 
usual exciting cause. Acute bronchitis is also an associated 
condition in certain infectious diseases, especially measles, 
whooping-cough, typhoid fever, and influenza. 

Pathology. — In most cases the trachea and large tubes 
only are affected. The mucous membrane is red, swollen, in- 
jected, and more or less covered with tenacious muco-pus. 

Microscopic examination reveals desquamation of epithe- 
lium and infiltration of the submucous tissues with leucocytes. 

Symptoms. — Chilliness; malaise; a sense of soreness and 
constriction behind the sternum, which is increased by cough- 
ing ; slight fever (100°-102°) with its associated symptoms; 
cough at first dry and painful, but later accompanied by 
mucopurulent expectoration which becomes quite free as the 
inflammation subsides. 

Physical Signs. — Inspection, palpation, and percussion 
usually give negative results. 

Auscultation at first reveals sibilant and sonorous rales on 
both sides of the chest, and in the second stage, when secretion 
is established, moist rales. 

Diagnosis. Influenza — High fever, intense pain in the 
head, back, and limbs, and great prostration will serve to dis- 
tinguish influenza from bronchitis when the former is prevalent. 



BRONCHITIS. 1 83 

Catarrhal Pneumonia . — Moderately high and irregular fever, 
prostration, rapid breathing, dyspnoea, and physical signs indi- 
cating consolidation will serve in the recognition of pneumonia. 

Prognosis. — Favorable. In the old, young, and feeble 
there is danger of its leading to capillary bronchitis or catar- 
rhal pneumonia. 

Treatment. — The abortive treatment consists in the use 
of hot foot-baths, a mustard plaster to the chest, the internal 
administration of hot drinks, and a full dose of Dover's pow- 
der (gr. x) with which quinine may be advantageously com- 
bined. This method is only applicable in the initial stage, and 
to those patients who are willing to remain indoors for the fol- 
lowing twenty-four hours. 

The young, old, and enfeebled should be confined to bed. 
A turpentine stupe, mustard plaster, or iodine may be applied 
to the chest. 

In the early stage when there is substernal pain with little 
or no expectoration, sedative expectorants, like ipecac, the veg- 
etable salts of potassium, antimony, and apomorphia are indi- 
cated ; and it is w 7 ell to combine with them an opiate to check 
the harassing cough. 

]£ Potass, citrat., ^ss ; 

Apomorphia? hydrochlor., gr. j ; 
Syr. ipecac, f Jss; 
Succi limonis, f^ij ; 

Syr. simp., q. s. ad f^iv. — M. (Wood.> 
Sig. — A dessertspoonful, in water, every three hours. 

Or— 

fy Villi ipecacuanha?, f^ij ; 

Liq. potass, citrat., f j§iv ; 

Tinct. opii camph., 

Syr. acacia?, aa f^j.— M. (DaCosta.) 
Sig.— Tablespoonful thrice daily. 

In severe cases with dyspnoea, inhalations from a steam 
atomizer often give relief. Wine of ipecac (with twice its 
volume of water), tincture of lobelia, or tincture of conium 
may be employed for this purpose. 

In the later stages, when expectoration has been established, 
stimulating expectorants are indicated ; chloride of ammonium, 
squills, senega, terebene, tar, or eucalyptus may be selected : — 



184 DISEASES OF THE KESPIKATORY SYSTEM. 

J$l Amnion, chlor., gr. xl ; , 
Syr. scillse, 
Tinct. opii cam ph., 
Ext. prim, virgin, fl., aa f^ss ; 
Syr acacise et aquae, aa q. s. ad f^ix. — M. 
Sig. — A tablespoonfnl every three hours. 

Or— 

fy Tinct. opii camph.. f^ij ; 

Syr. prim, virgin., fjiss ; 

Syr. picis liquids, q. s. ad f ^iv. — M. 
Sig. — A tablespoonfnl thrice daily. 

Or— 

^ Terebene, f.^ss. 
Sig. -Five drops on sugar, gradually increased to ten thrice daily. 

Chronic Bronchitis. 

(Chronic Bronchial Catarrh, Winter Cough.) 

Etiology. — It may result from the continuation of an 
acute attack ; but it most commonly develops gradually from 
the causes which induce the acute disease, namely, a cold, damp 
climate, changeable weather, gouty diathesis, chronic nephritis, 
and heart disease. It is especially common in the old. 

It is an associated condition in emphysema, phthisis, chronic 
interstitial pneumonia, and in many cases of asthma. 

Pathology. — The mucous membrane of the bronchi is 
sometimes thickened and roughened from an overgrowth of 
the connective tissue ; in other cases the mucosa is thin from 
atrophic changes. The surface is usually covered with muco- 
pus ; ulcers are occasionally noted. 

Long-standing bronchitis leads to dilatation of the tubes 
(Bronchiectasis) and to emphysema. 

Symptoms. — Persistent cough, and more or less muco-pnru- 
lent expectoration ; a sense of soreness behind the sternum. 
Fever is usually absent, and unless the disease is very severe, 
the general health may be fairly well preserved. Dyspnoea 
on exertion is a troublesome symptom ; it however belongs more 
to the resulting emphysema than to the bronchitis. 

Physical Signs. — Unless emphysema has developed, in- 
spection, palpation, and percussion give negative results. 



BRONCHITIS. 185 

Auscultation reveals rales, some of which are dry and 
wheezing, while others are moist and bubbling. 

Special Varieties. — (1) Rheumatic bronchitis. (2) Bron- 
chorrhcea. (3) Dry catarrh. 

Rheumatic Bronchitis. — This form occurs in those of a rheu- 
matic diathesis, and is characterized by severe paroxysmal 
cough, the expectoration of scanty tenacious mucus, and by 
aching pains in various parts of the chest. It is especially in- 
fluenced by atmospheric changes, and does not yield to the 
ordinary treatment of bronchitis. 

Bronchorrhcea. — This term is applied to cases of chronic 
bronchitis which are associated with a very copious expectora- 
tion. The sputum is generally muco-purulent, and sometimes 
very offensive (Fetid bronchitis). 

Dry Catarrh. — This form, described by Laennec as catarrhe 
sec, is characterized by severe spells of coughing which are 
accompanied by little or no expectoration. It is generally 
seen in the old in association with emphysema or asthma. 

Diagnosis. Phthisis. — The absence of fever, of hemorrhage, 
of bacilli in the sputa, and of signs indicating consolidation 
will serve to distinguish chronic bronchitis from phthisis. 

Bronchiectasis. — This often results from chronic bronchitis. 
Very profuse fetid sputa, expelled periodically in gushes, and 
perhaps physical signs of cavity over the main bronchi, poste- 
riorly, indicate bronchiectasis. 

Emphysema. — Much dyspnoea, distention of the chest, hyper- 
resonance on percussion, and a prolonged feeble expiration on 
auscultation indicate emphysema. 

Sequelae. — Emphysema, bronchiectasis, and dilatation of 
the right ventricle 

Prognosis. — Perfect recovery is rarely attainable, but the 
disease is not incompatible with long life. 

Treatment. — A careful regulation of the hygiene ; this 
includes attention to diet, clothing, bathing, exercise, etc. 
Bronchitis dependent on heart or kidney disease will require 
remedies directed to those organs. The general vitality is 
frequently reduced, and tonics like cod-liver oil, hypophos- 
phites, iron, quinine, and strychnia are often valuable adjuncts 
to the special treatment. A change of climate often secures 



186 DISEASES OF THE RESPIRATORY SYSTEM. 

permanent relief. In this country the extreme south-western 
territory, including New Mexico, Arizona, and Southern Cali- 
fornia, possesses many atmospheric advantages. 

Alteratives like iodide of potassium (gr. v-x thrice daily) are 
often serviceable in chronic bronchitis with little expectoration. 

Counter-irritants — blisters, tincture of iodine, or croton oil — 
prove useful. 

Stimulating expectorants — chloride of ammonium, terebene, 
tar, eucalyptus, oil of sandalwood, and copaiba — are generally 
indicated : — 

T$l Amnion, chlor., 

Ext. glycyrrhizse, aa .^ij ; 
Syr. lactucar. et aqua?, aa q. s. ad f ^vj. — M. 
Sig. — A tablespoonful thrice daily. 

Or— 

$. Copaiba?, ^iij ; 

Acacia? et sacchar. alb., aa q. s. ; 
Spt. lavandula? comp., f^ss ; 
Aqua?, q.s. ad f^vj. — M. 
Sig. — A tablespoonful thrice daily. 

Or— 

]£ Apomorphinse hydrochlor., gr. i ; 

Syr. prun. virg., f^ij ; 

Syr. picis liquidse, f^iv. — M. (Murrell.) 
Sig; — A tablespoonful thrice daily. 

Or— 

^ Terebene, fgss. 
Sig. — Five to ten drops on sugar thrice daily. 

The method of treating chronic bronchitis by inhalations, 
which has been so ably advocated by Dr. Murrell of London, 
is extremely useful, especially in patients with weak stomachs, 
in whom syrups should be avoided. 

Wine of ipecac (with twice its volume of water),- terebene 
(with equal parts of benzoinol or liquid vaseline), creasote, or 
carbolic acid may be so employed. 

I£ Acid, carbol., gr. xxx ; 

Tinct. opii camph., jfiij.— M. (K S. Davis.) 
Sig.— A fluid drachm with half a pint of hot water in the inhaler, 
thrice daily. 

An inexpensive inhaling apparatus is made bv Cod man cv. 
Shurtleff, of Boston. 



BRONCHITIS. 187 

Capillary Bronchitis. 

(Suffocative Catarrh.) 

Definition. — An inflammation of the smaller bronchi, 
generally secondary to simple bronchitis. 

Etiology. — Simple bronchitis is apt to involve the capil- 
lary tubes in the young, old, and debilitated. It is often a 
complication of certain infectious fevers — like measles, whoop- 
ing-cough, diphtheria, and influenza. 

Pathology. — The mucous membrane of the finer tubes is 
red, swollen, and injected, and the tubes are filled with tena- 
cious mucus. In most cases more or less catarrhal pneumonia 
results from the extension of the inflammation into the 
air-vesicles. Areas of collapse from occlusion of the bronchi 
are often observed. 

Symptoms. — Severe spells of coughing, which in children 
are unaccompanied with expectoration ; rapid respirations (60 
to 80 per minute) ; dyspnoea ; high fever (104°-105°) • and a 
weak, rapid pulse. Later the lips become blue, the extremities 
cold, and the mind dull, and death frequently results in a few 
days from exhaustion and asphyxia. 

Physical Signs. — Inspection reveals evidences of dyspnoea : 
Playing of the alee of the nose, blue lips, anxious face, promi- 
nent sterno-cleido-mastoids, and retraction of the base of the 
chest from obstruction to the entrance of air. 

Percussion. — The resonance may be normal, but large 
areas of collapse or pneumonic consolidation will yield dulness. 

Auscultation. — Weak breathing, and whistling sibilant rales 
or fine, crackling, moist rales. 

Diagnosis. Catarrhal Pneumonia. — This is a natural out- 
come of capillary bronchitis and usually complicates it. The 
detection of areas of consolidation in catarrhal pneumonia is 
the only diagnostic difference. 

(Edema of the Lungs. — The history of some chronic causal 
disease and the absence of fever will assist in the diagnosis of 
oedema. 

Prognosis. — In young children it is very grave. In older 
and more vigorous patients the prognosis is much more 
favorable. 



188 DISEASES OF THE RESPIRATORY SYSTEM. 

Treatment. — Absolute rest. The temperature of the room 
should be kept uniformly at 70° or 75°. The atmosphere 
should be rendered moist by the generation of steam. A tur- 
pentine stupe may be applied to the chest, which should be 
protected by a cotton jacket. The diet ought to be liquid or 
semi-liquid and nutritious. Stimulants are frequently indi- 
cated. Quinine may be given in suppository as a support to 
the system. Carbonate of ammonium is an invaluable cardiac 
and respiratory stimulant in these cases : — 

$. Amnion, carb., gr. xv ; 

Pulv. acacia? et sacchar., aa q. s. ; 
Spt. lavandulse comp.. fsjij ; 
Aqua?, q. s. ad fjfij. — M. 
Sig. — A teaspoonful every two hours to a child of two or three 
years. 

'When the dyspnoea is marked an emetic is useful in expel- 
ling mechanically mucus from the bronchi. Wine of ipecac 
(3ss-3j for a child) may be selected. 

When the fever is high, it should be reduced by sponging 
with cool water, or by the cold bath. 

Fibrinous Bronchitis. 

(Croupous Bronchitis, Pseudo-membranous Bronchitis.) 

Definition. — A primary inflammatory disease of the bronchi 
associated with the formation of false membrane. 

Etiology. — The causes are unknown. Male sex, early 
manhood, and chronic pulmonary disease, like phthisis, emphy- 
sema, and pleurisy, appear to be predisposing factors. 

Pathology. — The disease is often limited to a certain num- 
ber of bronchi. Some of the affected tubes are found filled 
with a fibrinous exudate, while others are found empty and 
show a loss of epithelium. The casts are usually expelled in 
the form of whitish balls, and when unrolled in water present 
branching moulds of the divisions and subdivisions of the 
affected bronchi. On close examination they are found to be 
hollow and laminated. Under the microscope, a homogeneous 
or fibrillated membrane is observed, imbedded in which are 



DILATATION OF THE BRONCHIAL TUBES. 180 

leucocytes, fat-drops, particles of pigment, epithelial cells, and 
occasionally Leydeh's octahedral crystals. 

Symptoms. — Acute and chronic forms are recognized. The 
former is rare, and manifests the symptoms of a severe attack 
of acute bronchitis, but the sputa contain fibrinous casts, and 
there is marked dyspnoea. 

The chronic form is characterized by severe cough, parox- 
ysms of dyspnoea, and the expectoration of fibrinous plugs. 
The physical signs are those of chronic bronchitis. The disease 
often lasts a few weeks, and then disappears to return again at 
definite periods. 

Prognosis. — In the acute variety the prognosis must be 
guarded : death frequently results from suffocation. 

The chronic variety runs a very protracted course. 

Treatment. — In the acute disease, the atmosphere of the 
room should be kept moist and uniformly warm. Calomel 
(gr. J every two hours) may be administered as in other mem- 
branous inflammations, and may be followed by iodide of 
potassium. Inhalations of alkaline vapors (lime-water) exert 
a solvent effect. Counter-irritants should be applied to the 
chest. Emetics sometimes aid in the expulsion of casts. 

In the chronic form iodide of potassium may be given in 
conjunction with stimulating expectorants. 

DILATATION OF THE BRONCHIAL TUBES. 

( Bronchiectasis . ) 

Definition. — A universal or circumscribed dilatation of 
the bronchi. 

Etiology. — Chronic inflammation of the tubes and the 
contraction of surrounding pulmonary tissue are the prime 
causes ; hence, it is generally secondary to chronic bronchitis, 
phthisis — particularly fibroid — chronic interstitial pneumonia, 
and chronic pleurisy with adhesions. 

Pathology. — The dilatation results from weakening and 
atony of the tubes, and from their subjection to strain in 
coughing, or to the traction of shrinking connective tissue, as 
in fibroid phthisis. 

Two forms are noted: (1) The cylindrical form, in which 



190 DISEASES OF THE RESPIRATORY SYSTEM. 

the tubes, particularly those of medium size, are uniformly 
dilated in one or both lungs ; and (2) the saccular form, in 
which the tubes swell out, here and there, into circumscribed 
dilatations which may reach several inches in diameter. This 
form is especially noted in fibroid phthisis. The walls of the 
bronchiectatic cavity are extremely atrophied, the surface is 
generally smooth and shining, but ulcerations are not un- 
common. 

Symptoms. — Cough, dyspnoea, and copious expectoration. 
The last is characteristic; it is apt to occur periodically in 
gushes ; the material has a highly offensive odor, and when 
allowed to stand in a glass vessel separates into three layers : 
an upper layer of dirty brown froth, a middle layer of turbid 
mucus, aud an under layer of decomposed pus. Microscopi- 
cally it contains pus corpuscles, fat crystals, crystals of hsema- 
toidin, and numerous microorganisms, but no tubercle bacilli. 
Elastic fibres are rarely found. 

Physical Signs. — In the cylindrical variety the signs are 
those of chronic bronchitis. The saccular variety may present 
the signs of tuberculous cavities, localized tympany, cavernous 
breathing, gurgling rales, and pectoriloquy. 

Diagnosis. — The differentiation of bronchiectasis from 
phthisis is difficult and often impossible. The discovery of 
tubercle bacilli always indicates phthisis. Bronchiectatic cavi- 
ties are usually located in the lower lobes, and rarely in the 
apices. 

Prognosis. — This will depend on the primary disease ; 
since the common causes are long-standing bronchitis and 
fibroid phthisis, there can be little hope of cure. Amelioration 
is all that can be expected. 

Treatment. — Tonics are often indicated. Stimulant and 
antiseptic expectorants like turpentine, terebene, eucalyptus, 
oil of sandalwood, and tar are sometimes useful. 

Inhalations of terebene, carbolic acid, or dilute peroxide of 
hydrogen lessen cough and destroy the fetid odor of the breath. 
Codein (gr. J) may be employed to allay cough. 



ASTHMA. 191 



ASTHMA. 



Definition. — Paroxysmal dyspnoea clue to spasm of the 
tubes or to swelling of their mucous membrane. 

Etiology. — Asthma is a symptom of several diseases, but 
a hypersensitive condition of the mucous membrane of the re- 
spiratory tract appears to be essential to its production. When 
this condition prevails, asthma may be induced (1) by the pul- 
monary congestion of cardiac disease (Cardiac asthma); (2) 
by the ursemic intoxication or transient pulmonary oedema of 
Bright's disease (Renal asthma) ; or (3) by some irritant from 
without, as the pollen of plants (Hay asthma). (4) Sometimes 
the paroxysms are excited by the most trivial causes, as an 
atmospheric change or a peculiar odor, and to this form many 
writers restrict the term asthma. This last will be discussed 
under the head of essential asthma. 

Essential Asthma. 

(Bronchial Asthma, Nervous Asthma, Spasmodic Asthma.) 

Etiology. — Nervous temperament, an hereditary tendency, 
early life, disease of the naso-pharynx, and the gouty diathesis, 
are predisposing factors. 

Barometric and thermometric changes; the inhalation of 
dust; the odor of certain plants, animals, or fruits; excite- 
ment ; reflex irritation, particularly a loaded stomach ; a 
change of locality ; and bronchial catarrh, are exciting causes. 

Pathology. — The disease is a pure neurosis, and the par- 
oxysms probably result from a spasm of the smaller tubes, or 
turgescence of their mucous membrane. 

Symptoms.— The paroxysms often appear suddenly, but in 
some cases certain symptoms precede and give warning of the 
approaching attack ; among these are chilliness, flatulence, 
sneezing, and a copious discharge of pale urine. The patient 
is often seized at night. There is a sense of oppression and 
anxiety followed by dyspnoea so intense that he runs to the 
window for air, or sits upright with his arms in such a position 
that he can bring into play the auxiliary muscles of respiration. 
The face is pale, the lips blue, the eyes prominent and con- 



192 DISEASES OF THE RESPIRATORY SYSTEM. 

gested, and the body cold and covered with sweat. The re- 
spirations are not rapid, but labored and noisy. Cough is often 
present and is associated with the expectoration of scanty 
viscid mucus. On close examination little grayish balls are 
noted in the sputum, and when unravelled, they are found to 
be composed of delicate spirals of mucus, which have been 
moulded in the finer bronchioles (Curschmann's spirals). 

Fig. 16 




Curscrmianri's Spirals, a, Central fibre. 



Microscopic examination also reveals octahedral crystals 
similar to those found in leukaemia (Charcot-Leyden crystals). 

The paroxysms may last from a few minutes to many hours, 
and may recur for several successive nights, or may disappear 
entirely for weeks or months. 

Physical Signs.- — Inspection reveals evidences of dyspnoea 
and distention of the chest. 

Percussion, generally yields hyper-resonance. 

Auscultation. — A prolonged, high-pitched, wheezing expira- 
tion, with abundant sonorous and sibilant rales. The expira- 
tory wheezing may be audible over the entire room. 

Diagnosis. — Cardiac and 'renal asthma are to be distin- 
guished from essential asthma by the history, and by the evi- 
dence of organic heart or kidney disease. 

Hay asthma is recognized by the associated coryza and by 
its periodic occurrence every spring or fall. 






ASTHMA. 1 93 

Laryngeal obstruction from foreign bodies, croup, paralysis 
of the vocal cords, or oeclemi. — The dyspnoea is with inspira- 
tion, and the chest instead of being distended is retracted, 
especially at the base. 

Sequelae. — Emphysema invariably follows when the 
asthma is of long duration ; it results from the tension to 
which the vesicles are subjected daring the expiratory effort. 
Dilatation of the right ventricle is also a remote sequel. 

Prognosis. — The disease does not prove fatal except 
through complications or sequelae. In young persons without 
an inherited tendency the prognosis should be guardedly 
favorable ; it frequently subsides at puberty. Cases associated 
with some definite reflex cause, as nasal obstruction, often 
recover when the latter is removed. The older the patient, the 
greater the inherited tendency, the more unfavorable becomes 
the prognosis. 

Treatment. The Attach. — Prompt relief often follows 
the inhalation of nitrite of amyl (five or six drops in a glass 
or on the handkerchief), iodide of ethyl (twenty to thirty 
drops), or a few whilfs of chloroform. Smoking cigarettes of 
belladonna and stramonium leaves wrapped in nitre-paper — 
paper which has been soaked in a saturated solution of salt- 
petre and dried — will often suffice in mild attacks. Nitre- 
paper may be burned in the room and the fumes inhaled. 

The application of dry cups or thin poultices to the chest is 
often a valuable adjunct to the treatment. Morphia (gr. J-J) 
with sulphate of atropine (gr. T ^) will often cut short an 
attack. Internally, sedatives like Hoffmann's anodyne (5ss), 
tincture of lobelia (ni xx), and bromide of potassium (gr. xxx), 
are sometimes useful. 

^ Potass, bromid., ^iij ; 
Tinct. lobelige, fgiij ; 
Spt. aether, comp., f.^j ; 
Ext. grindelise rob. fl., f^ss ; 
Syr. sarsaparillse comp., q. s. ad fjiv. — M. 
Sig. — A dessertspoonful in water every two hours. 

The Interval. — -Careful search should be made for some re- 
flex irritation, especially in connection with the naso-pharynx. 
An easily-assimilable diet must be selected ; in nocturnal 
13 



194 DISEASES OF THE KESPIRATOKY SYSTEM. 

asthma the evening meal should be very light. Graduated ex- 
ercise and frequent bathing, followed by friction of the skin, 
will add to the general vigor. A change of climate is de- 
sirable, but there is no fixed rule in the selection of locality. 
Many asthmatics do well in the city, but a dry atmosphere 
and a high altitude are better suited to the majority. Busey 
claims excellent results from the habitual wearing of an oil- 
silk jacket in asthma associated with bronchitis. Among the 
remedies arsenic and iodide of potassium hold a high place as 
alteratives. Fowler's solution (three drops, gradually increased 
to ten or more, thrice daily), or ten to twenty grains of the 
iodide may be administered over long periods. Nitroglycerin 
(gr. y-{po)j or nitrite of sodium (gr. iij-v thrice daily) often gives 
immunity for long periods. 

HAY ASTHMA. 

(Hay Fever, Autumnal Catarrh, Rose Cold.) 

Definition. — A catarrhal affection of the respiratory tract, 
usually occurring periodically every spring or autumn, excited 
by the action of some atmospheric irritant upon a hyperses- 
thetic mucous membrane, and characterized by coryza, bron- 
chitis, and asthmatic seizures. 

Etiology. — An inherited tendency, male sex, nervous tem- 
perament, indoor life, and chronic nasal catarrh are predis- 
posing factors. The attack as a rule occurs in the autumn 
(Autumnal catarrh), or in the spring (Rose cold), and is excited 
by certain dusts, vapors, or odors. The pollen of plants seems 
to be a common excitant. The seizures may occur at any 
time if the peculiar irritant is present. 

Pathology. — An essential feature is the hypersensitive 
condition of the mucous membrane, and this is often, though 
not invariably, associated with hypertrophic rhinitis. 

Symptoms. — Redness of the conjunctiva? and swelling of 
the eyelids ; pruritus of the pharynx, nose, and eyes ; sneez- 
ing ; obstruction of the nostrils ; watering of the eyes ; a 
copious discharge of mucus from the nose ; headache ; cough ; 
and asthmatic attacks are the usual phenomena. 

Rose cold usually begins in May or June and runs to the 



PULMONARY EMPHYSEMA. 195 

latter part of July. Autumnal catarrh begins in the latter 
part of August and ends with the first frost. 

Prognosis. — The disease runs an indefinite course, and 
rarely, if ever, proves fatal. Cases which are associated with 
chronic rhinitis often permanently recover on the removal of 
the latter. In other cases, the prognosis as regards immu- 
nity from future attacks is unfavorable. 

Treatment. — Careful search should be made for chronic 
nasal disease, and if found, appropriate treatment instituted. 

A change of climate during the period of susceptibility 
exempts most patients. A sea-voyage or a sojourn in some 
high-mountain district, like the White Mountains, Adiron- 
dacks, Catskills, or Alleghanies may be recommended. 

Tonics are usually indicated, and quinine, arsenic, and 
strychnia are often very useful when administered before and 
during an attack. To allay itching and lachrymation, the 
eyes may be washed with a solution of boric acid (gr. x to 3j), 
or sulphate of zinc (gr. i-ij to %j). Sneezing, nasal fulness, 
and discharge are often relieved by medicated sprays. A solu- 
tion of cocaine, or the following may be employed : — 

T$l Menthol, 3j-3ij ; 

01. amygd. dulc. vel benzoinol, f^ij-M. 
Sig. — Spray into the nose and throat every lew hours. 

PULMONARY EMPHYSEMA. 

Definition. — Abnormal distention of the lungs with air. 

Varieties. — (1) Interlobular emphysema : This form is 
rare, and results from the rupture of the lung and escape of 
air into the interstitial tissue. (2) Compensatory emphysema : 
When a lung or a part of a lung is disabled from any cause, 
the healthy portions distend and do vicarious work. (3) 
Atrophic or senile emphysema: In old people the solids of 
the lung atrophy, so that a relative increase of air results. 
(4) Hypertrophic emphysema. The last three varieties are 
included under the term vesicular emphysema. 



196 DISEASES OF THE KESPIRATORY SYSTEM. 

Hypertrophic Emphysema. 

Definition. — A pulmonary disease characterized anatomi- 
cally by dilatation of the air- vesicles and atrophy of the walls ; 
and clinically by dyspnoea, enlargement of the thorax, hyper- 
resonance, and weak breathing. 

Etiology. — Congenital weakness of the lung structure — 
probably a defective development of elastic tissue — is an im- 
portant predisposing factor. This predisposition may be trans- 
mitted through several generations. 

In forced expiration, the air cannot escape with sufficient 
rapidity through the narrow glottis, and the backward pres- 
sure stretches the air-vesicles ; hence, the obstinate cough of 
chronic bronchitis, the expiratory straining of asthma, and 
occupations which necessitate forced expiration, like playiug 
on wind instruments and glass-blowing, are causal factors. 

Pathology. — The lungs are enlarged, and do not collapse 
when the thorax is opened. In bad cases the free margins are 
studded with large bullae or blebs which have resulted from 
the rupture of a number of vesicles into a common sac. The 
organs are pale, and have a soft cotton-like feel. Microscopic 
examination reveals atrophy of the vesicular walls, a dimin- 
ished amount of elastic tissue, and more or less obliteration of 
the pulmonary capillaries. This last condition leads to in- 
creased tension in the pulmonary artery and to secondary 
hypertrophy of the right ventricle. 

Symptoms. — The disease generally manifests itself in middle 
life, but it is not infrequently observed in the young. Dys- 
pnoea, increased by exertion ; cyanosis, often extreme during 
attacks of acute bronchitis ; and cough, from the associated 
bronchitis, are the usual symptoms. In advanced cases dropsy 
may result from cardiac failure. 

Physical Signs. — The neck is short, and the sterno- 
cleido-mastoids prominent. The thorax is likewise short, but 
broad especially in its antero-posterior diameter. This con- 
figuration has given rise to the term " barrel-shaped" chest. 
On respiration there is little expansion, but an elevation of 
the thorax as a whole. The apex-beat is invisible, but an 
abnormal pulsation is often noted in the epigastrium. 



PULMONARY EMPHYSEMA. 197 

Palpation. — Diminished vocal fremitus. 

Permission. — Increased resonance. The upper level of 
hepatic dulness is depressed, and the area of cardiac dulness 
may be almost obliterated. 

Auscultation. — Inspiration is short, expiration is prolonged 
and low-pitched, or inaudible. Rales resulting from the asso- 
ciated bronchitis are frequently heard. The pulmonary second 
sound is accentuated. 

Complications.— Bronchitis, asthma, dilatation of the 
right ventricle, and later, tricuspid regurgitation and dropsy. 

Diagnosis. Chronic Bronchitis. — The dyspnoea, thoracic 
enlargement, hyper-resonance, and prolonged expiration sepa- 
rate emphysema from bronchitis. 

Pneumothorax. — This is almost invariably unilateral, the 
resonance is tympanitic, and metallic tinkling and bell- 
tympany are obtained on auscultation. 

Prognosis. — The disease is generally incurable ; but its 
advance may be stayed by relieving the primary condition. 
Emphysema runs a long course and is in itself rarely fatal, 
but death may result from heart failure and dropsy, or from 
intercurrent pneumonia. 

Treatment. — The remedies advocated in chronic bron- 
chitis and asthma are often applicable here. The patient 
should be placed under the most favorable hygienic conditions. 
Iodide of potassium (gr. x thrice daily) is often used empiri- 
cally, and sometimes relieves the dyspnoea and cough. Iron 
is indicated in the anaemic. Strychnia (gr. ^g- - sV) ^ s a va ^ l1_ 
able respiratory and cardiac stimulant, and may be combined 
with digitalis when there are symptoms of heart failure. 

fy_ Strychnin, sulph., gr. h ; 

Pulv. digitalis, 

Pulv. scilke, 

Ferri redact., aa gr. xx.— M. 
Ft. in pil. No. xx. 
Sig. — One thrice daily. 

The inhalation of oxygen, or the inspiration of compressed 
air followed by expiration into rarefied air is sometimes a useful 
measure. 



198 DISEASES OF THE RESPIRATOKY SYSTEM. 

HAEMOPTYSIS. 

(Bronchorrhagia, Broncho -pulmonary Hemorrhage.) 

Definition. — The expectoration of blood. 

Etiology. — (1) Vicarious menstruation (rare). (2) Trau- 
matism. (3) Inflammatory diseases of the respiratory tract, 
especially phthisis and pneumonia. (4) The rupture of an 
aortic aneurism. (5) Obstruction to the venous circulation 
as in chronic heart and liver disease. (6) Malignant disease 
of the lung. (7) A dyscrasia of the blood, as in purpura, the 
infectious fevers, haemophilia (bleeder's disease), and scurvy. 
(8) It occasionally occurs in young people without obvious 
cause. 

Symptoms. — Sometimes the bleeding is preceded by cough, 
dyspnoea, or substernal warmth or tenderness, but often there 
is no premonition, and the first indication is the presence of a 
warm salty fluid in the mouth. The blood is generally raised 
by coughing, and is bright red and frothy. It is alkaline in 
reaction, and intimately mixed with air and mucus. The 
hemorrhage is rarely profuse unless it results from the rupture 
of an aortic aneurism or the ulceration of a large vessel in ad- 
vanced phthisis. Auscultation of the chest reveals bubbling 
rales. The subsequent expectorations are tinged with blood, 
and if much is swallowed it may excite vomiting or pass into 
the intestine and impart a tarry appearance to the stools. 

Diagnosis. — Hcemopti/sis must be distinguished from hcema- 
temesis : — 



HEMOPTYSIS. 

History of some chest disease. 



Hematemesis. 



History of some abdominal dis- 
ease. 

The blood is ejected by coughing. The blood is ejected by vomiting. 
The blood is bright red and The blood is dark, and dense or 

frothy. clotted. 

The blood is mixed with sputum. The blood is mixed with food. 
The blood is alkaline in reaction. The blood is acid in reaction. 
The subsequent expectorations The subsequent expectorations 
are tinged with blood, and the contain no blood, and the stools 
stools are rarely tarry. are frequently tarrj^. 

Auscultation reveals rales. Auscultation gives negative re- 

sults. 



PULMONARY APOPLEXY. 199 

Prognosis. — Haemoptysis is rarely the cause of death in 
the disease in which it occurs. In phthisis the symptoms 
often improve after a moderate hemorrhage. On the other 
hand, in aneurism, advanced phthisis, and abscess and gan- 
grene of the lung, the bleeding may prove fatal. 

Treatment. — Absolute rest and the avoidance of excite- 
ment. The shoulders should be elevated ; an ice-bag may be 
placed on the chest, and pieces of ice may be held in the mouth, 
and slowly swallowed. Morphia is generally required as a 
sedative; it may be given hypodermically with ergotin (gr. 
v-x) or with the fluid extract of ergot (X x-xx). Gallic acid 
(gr. x-xx) may be given by the mouth. Astringent sprays 
are useless. A saline purge may act beneficially by inviting 
blood away from the congested organ. A firm ligature around 
one or both legs retards the flow of venous blood, and so aids 
in arresting the hemorrhage. 

When the bleeding is not profuse, but frequently repeated, 
the following internal remedies are efficient : Acetate of lead 
gr. ij with powdered opium gr. J, gallic acid (gr. x-xx), fluid 
extract of hamamelis (5j-3 n j)> turpentine (gtt. x), or — 

I£ Acid, gallic, giiss ; 

Acid, sulph. aromat., fgj ; 
Glycerin., fgss ; 
Aquae, q. s. ad f §iv— M. 
Sig. — A tablespoonful thrice daily. 

PULMONARY APOPLEXY. 

(Hemorrhagic Infarction of the Lung.) 

Definition. — An effusion of blood into the pulmonary 
tissues. 

Etiology. — It may result from degeneration of the pul- 
monary vessels, but it is most frequently due to an embolism 
in one of the branches of the pulmonary artery. The em- 
bolism is usually a portion of thrombus which has formed in 
the heart or in one of the systemic veins. Occlusion of the 
vessel causes a backward flow of blood, the part becomes en- 
gorged, and effusion follows. 



200 DISEASES OF THE RESPIRATORY SYSTEM. 

Pathology. — The infarction is usually located in the 
periphery of the lung ; it is conical in shape with its apex 
pointing inwards. The portion affected is airless, and reveals 
an infiltration of dark blood. Microscopic examination shows 
a dense aggregation of blood-corpuscles. 

If it does not prove fatal, absorption and subsequent fibroid 
induration result. 

Symptoms. — When the infarction is large the usual symp- 
toms are dyspnoea, cough, and the expectoration of dark blood 
containing few air-bubbles. These symptoms occurring in 
chronic heart-disease are especially suggestive. 

Physical Signs. — Very large infarctions give dulness and 
bronchial breathing. 

Treatment. — The condition itself is not amenable to treat- 
ment. Remedies should be directed to the primary disease. 



CONGESTION OF THE LUNGS. 
Active Congestion. 

Etiology. — This results from increased afflux of blood to 
the lungs. Hypertrophy of the heart, violent exercise, moun- 
tain-climbing, the inhalation of irritants, and mental excitement 
occasionally produce it. It is an associated condition in all 
severe inflammatory diseases of the lungs. In the vast 
majority of cases it marks the initial stage of croupous pneu- 
monia. 

Pathology. — The lung is bright red in color, heavy, and 
less crepitant. When incised and pressed, copious frothy 
blood exudes. 

Symptoms. — Flushed face ; dyspnoea ; short, dry cough, 
followed by tenacious blood-streaked expectoration ; and a 
rapid, full pulse. Physical examination reveals slight dulness 
and crepitant rales. 

Treatment. — Rest ; liquid diet ; wet cups to the chest. 

Internally. — Veratrum viride and a saline purge. 



CONGESTION OF THE LUNGS. 201 

Passive Congestion. 

Etiology. — This results from obstruction to the flow of 
blood from the lungs to the heart. The chief cause is cardiac 
disease, especially fatty degeneration, dilatation, and mitral 
disease. 

Pathology. — The lungs are dark red in color, and often 
somewhat (edematous. When "the condition has lasted a long 
time, the organs become brown, dense, and tough (brown in- 
duration). Microscopic examination reveals a dilatation of 
the capillaries, an overgrowth of connective tissue, free pigment 
granules, and degenerative changes in the bloodvessels. 

Symptoms. — Dyspnoea ; hard cough ; mucous expectoration 
containing pigmented cells. Physical examination only de- 
termines the presence of rales. 

Treatment. — Remedies should be directed to the under- 
lying cardiac disease. The application of dry cups often gives 
temporary relief. Saline laxatives may prove useful. 

Hypostatic Congestion. 

(Hypostatic Pneumonia, Splenization of the Lung.) 

Definition. — A congestion of dependent portions of the 
lungs occurring in asthenic diseases which necessitate a pro- 
tracted recumbent position. 

Etiology. — It is generally observed in low fevers and in 
chronic wasting diseases. (1) Blood-dyscrasia, (2) a weak 
heart, and (3) a recumbent position are the causal factors. 

Pathology. — The lungs are dark red and oedematous pos- 
teriorly. The oedema and increased amount of blood render 
the organs more solid and less crepitant. They never show 
the granular appearance of croupous pneumonia. 

Symptoms. — Dyspnoea, cough, and scanty expectoration. 

Physical examination reveals slight dulness, suhcrepitant 
rales, and feeble bronchial breathing. 

Treatment. — Efforts should be made to prevent the de- 
velopment of hypostatic pneumonia in asthenic disease by 
frequent change of position, and the timely use of such cardiac 



202 DISEASES OF THE RESPIRATORY SYSTEM. 

stimulants as alcohol, strychnia, digitalis, ammonia, and tur- 
pentine. When already present, turpentine stupes or dry cups 
may be applied externally, and one or more of the above 
stimulants administered internallv. 



CROUPOUS PNEUMONIA. 

(Lobar Pneumonia, Pneumonitis, Lung Fever.) 

Definition. — An acute specific disease, characterized ana- 
tomically by an inflammation of the lungs, followed by a 
rapid infiltration of their alveoli ; and manifested clinically by 
high fever, cough, dyspnoea, "rusty" sputum, and physical 
signs indicative of consolidation. 

Etiology. — Age, sex, and climate exert but little predis- 
posing influence. Lowered vitality from bad hygiene or from 
some pre-existent disease, like diabetes, Bright' s disease, or one 
of the infectious fevers, favors its development. One attack 
renders the patient more liable to subsequent infection. Alco- 
holism is a strong predisposing factor. Exposure to cold and 
wet often precipitates the attack. 

The exciting cause is unquestionably a microorganism, pro- 
bably Frankel's diplococcus pneumonia?. 

Pathology. — Anatomically three stages have been recog- 
nized : (1) The stage of congestion ; (2) of red hepatization ; 
(3) of gray hepatization. 

Stage 1. — The affected portion remains distended when the 
chest is opened ; it is of a deep-red color, and is more resistant 
■to the touch than the normal lung. On section, a frothy blood- 
stained serum freely exudes. Microscopic examination reveals 
a dilated and tortuous condition of the capillaries, swelling of 
the alveolar cells, and a slight corpuscular exudate. 

Stage 2. — The hepatized portion is increased in volume, is 
quite firm, is of a dark-red color, and so heavy that it sinks 
in water. It is very friable, and the torn surface presents a 
granular appearance from the projection of the fibrinous plugs 
in the alveoli. 

Microscopic examination reveals a mesh of coagulated fibrin, 
enclosing numerous red blood-corpuscles and some leucocytes ; 



CROUPOUS PNEUMONIA. 203 

the latter are also noted in the interlobular tissue. In sections 
properly treated the diplococcus is detected. 

Stage 3. — The red color gives place to a mottled gray, and 
the solidified lung begins to soften. The change in color is 
due to the compression of the capillaries, to the disappearance 
of red corpuscles and their replacement by leucocytes, and to 
fatty degeneration of some of the elements. 

In favorable cases resolution occurs before gray hepatization 
has far advanced, the exudation being removed by absorption 
and expectoration. 

In unfavorable cases the consolidated lung may become in- 
filtrated with pus (Purulent infiltration); it may become 
gangrenous; or, very rarely, it may become the seat of fibroid 
induration (Chronic interstitial pneumonia)./ 

Death may result early in the disease from the generated 
blood-poisons, or from rapid diminution of the respiratory 
surface. 

The consolidation usually begins at the base and extends 
upwards. The most frequent seat is the lower lobe of the 
right lung. The bronchi and the adjacent pleura are involved 
in the inflammatory process. 

Symptoms. — The disease usually begins with a decided 
chill and a sharp pain in the side, followed by a rapid rise of 
temperature ; the latter often attains its maximum (104°-105°) 
in twenty-four hours, and generally continues high, with slight 
diurnal remissions, until the ninth day, when it falls by crisis, 
frequently reaching the norm by the tenth day. Occasionally 
the temperature falls by lysis- There is marked dyspnoea ; 
the respirations are shallow and rapid, ranging from 40 to 80 
per minute, thus making the ratio between respiration and the 
pulse 1 to 3 or 1 to 2. Cough is a prominent symptom ; at 
first it is short and dry, but later it is accompanied by bloody 
(" rusty "), translucent, and tenacious sputa. Microscopically 
the sputum contains red blood-corpuscles, their free pigment, 
pus-corpuscles, diplococci, and other microorganisms. The 
face is flushed; the lips are cyanosed and often the seat of an 
herpetic eruption ; the tongue is heavily furred ; the bowels 
are constipated ; and the urine is scanty, high-colored, de- 



204 DISEASES OF THE RESPIRATORY SYSTEM. 

ficient in chlorides, and often slightly albuminous. In severe 
cases delirium is rarely absent. 

Physical Signs. Inspection. — Diminished expansion, but 
no bulging of the interspaces or displacement of the apex-beat. 

Palpation. — Diminished expansion and increased vocal 
resonance. 

Percussion. — At the onset there may be tympany over the 
affected area from diminished intra-pulmonary tension. As 
consolidation advances the note becomes remarkably dull. 
Exaggerated resonance is noted around the hepatized areas. 

Auscultation. — In the stage of congestion fine crepitant rales 
are heard at the end of forced inspiration; they probably 
result from the forcible separation of adherent vesicular walls, 
and disappear when the lung becomes solidified. Auscultation 
then detects increased vocal resonance, and harsh breathing 
which is prolonged, high-pitched, and tubular in expiration 
(bronchial). 

During resolution the softened exudate produces fine moist 
rales — the red ux-crepitus. 

Atypical Cases. Senile Pneumonia. — The symptoms often 
develop insidiously ; the temperature may not be high ; the 
pulse may not be accelerated ; expectoration is often absent ; 
the signs are not marked ; delirium is common ; weakness is 
extreme; and death from exhaustion is the most frequent 
termination. 

Pneumonia in Children. — It is often ushered in with con- 
vulsions. Headache, delirium, stupor, and coma are promi- 
nent symptoms, so that the disease may simulate meningitis. 
The temperature is very high ; expectoration is often absent. 
The disease frequently begins at the apex of the lung. 

Typhoid Pneumonia. — Pneumonia associated with typhoid 
symptoms, — - headache, muttering delirium, stupor, a dry, 
brown tongue, subsultus tendinum, carphologia, a rapid, weak 
pulse, and high fever which, in favorable cases, falls by lysis. 
The expectoration is often like prune-juice. 

Pneumonia of Drunkards. — The onset is gradual; the ex- 
pectoration is like prune-juice ; the temperature is not high, 
but a violent maniacal delirium commonly develops and is 
followed by death from exhaustion. 



CROUPOUS PNEUMONIA. 205 

Complications. — Pleurisy, pericarditis, endocarditis, oedema 
of the lungs, delayed resolution (consolidation may last five or 
six weeks, and then disappear), abscess of the lung, gangrene 
of the lung, and chronic interstitial pneumonia. 

Diagnosis. Pleurisy. — Here the initial chill is not so 
marked ; the fever is not so high nor the pulse so rapid ; and 
there is no "rusty" sputum ; but bulgiDg and displacement of 
the" apex-beat are often noted on inspection ; the percussion-d ill- 
ness may change with the posture of the patient ; vocal reso- 
nance and vocal fremitus are diminished; and the breathing 
is distant and weak. 

Acute Phthisis. — Irregular fever, bacilli in the sputum, and 
the continuation of grave symptoms with signs of softening 
after the ninth or tenth day, will suggest the diagnosis of tuber- 
culosis. 

Pulmonary GZdema. — Here there is absence of chill, fever, 
and pain ; the expectoration is watery, not " rusty ;" both 
lungs are commonly affected ; auscultation reveals abundant 
subcrepitant rales and weak breathing. 

Typhoid Fever. — Typhoid pneumonia may be readily mis- 
taken for typhoid fever with pneumonia ; but pneumonia as a 
complication occurs late in the disease, so that the history of 
the onset gives much assistance. 

The rose-red rash will indicate typhoid fever. 

Prognosis. — In patients previously healthy, the prognosis 
is good. At the extremes of life the outlook is grave. In 
drunkards the disease is especially fatal. 

In individual cases, a very high fever, great dyspnoea and 
cyanosis, rapidly increasing consolidation, involvement of both 
lungs, and a dark sputum are unfavorable factors. 

The average mortality is 20 per cent. 

Treatment. — Absolute rest. A liquid or semi-liquid diet 
(milk, koumiss, eggs, broths, beef juice). The chest should be 
enveloped in a cotton jacket covered with oiled silk. 

Although pneumonia is an infectious disease which produces 
widespread disturbance in the economy, the immediate danger 
is generally obstruction to the pulmonary circulation ; so that 
in the stage of congestion, when the pulse is full and strong, 
veratrum viride (^l iij-v of the fluid extract every hour until 



206 DISEASES OF THE RESPIRATORY SYSTEM. 

the pulse softens) is a valuable remedy. It depresses the 
heart, dilates the systemic vessels, and so invites blood away 
from the engorged lung. In the very robust, venesection may 
be substituted for veratrum. 

In consolidation, the right ventricle is subjected to a strain 
and there is danger of heart failure ; hence cardiac stimulants 
are indicated in this stage. The tincture of digitalis (gtt. x 
every two or three hours, being guided by the pulse) may be 
given by the mouth ; when the stomach is irritable, the drug 
should be administered hypodermically. Strychnia (gr. g 1 ^) 
is also of great value as a cardiac and respiratory stimulant. 
Ammonia is useful in some cases, and either the aromatic 
spirits or the carbonate may be employed. 

In mild cases quinine (gr. v thrice daily) will be the only 
internal remedy required. 

As a general stimulant and food, alcohol is often indicated. 
In typhoid pneumonia turpentine ("I v) may be associated 
with the alcohol. 

Pain may be relieved by opium, or by the application of 
wet cups, dry cups, or hot fomentations. 

Delirium, — Apply an ice-bag to the head, and administer 
bromide of potassium, hyoscine, musk, or camphor internally. 
When the delirium is associated with high fever, a cold pack 
or tepid bath will often control it. 

Pyrexia. — Occasionally, high fever will require treatment ; 
sponging, a cold pack, or a cold bath (80°) may be employed. 
Antipyrin (gr. vj) is a safe and efficient remedy. 

Convalescence should be guarded, and such tonics as iron, 
quinine, strychnia, and cod-liver oil will be found useful resto- 
ratives. 

In delayed resolution, small blisters may be applied over the 
affected areas, and iodide of potassium may be administered 
internally. Thus : — 

Potass, iodid., 3J ; 
Amnion, chlor., ^iss ; 

Mist, glycyrrbizae comp. , f^vj. — M. (Da Costa. ) 
Sig. — Tablespoonful four times a day. 






CATARRHAL PNEUMONIA. 207 

CATARRHAL PNEUMONIA. 

(Broncho-pneumonia, Lobular Pneumonia, Insular Pneumonia.) 

Definition. — An inflammation of the terminal bronchioles 
and air-vesicles, characterized anatomically by scattered areas 
of consolidation which are composed almost entirely of leuco- 
cytes and desquamated epithelium ; and manifested clinically 
by moderately high and irregular fever, dyspnoea, cough, and 
physical signs indicative of insular consolidation. 

Etiology. — The disease is generally secondary to bronchitis, 
and the causes which predispose to an extension of the inflam- 
mation from the bronchi to the air-vesicles are : Childhood 
and old age ; the infections fevers, especially measles, whoop- 
ing-cough, diphtheria, and influenza ; and low vitality. 

Another group of cases results from the aspiration of mucus, 
pus, or particles of food into the smaller bronchi. This is 
liable to occur from any cause which renders expectoration im- 
perfect, as the coma of apoplexy, the stupor of typhoid fever, 
bulbar palsy, tracheotomy, and advanced paretic dementia. 

Pathology. — As a rule, both lungs are involved. On 
section, small projecting areas of consolidation are noted here 
and there around the finer bronchioles. Recent patches are 
reddish-brown in color, firm, and smooth or finely granular ; 
later they become grayish and soft. The terminal bronchi 
are filled with purulent material. 

In addition to these solidified areas, there are other small 
patches of collapsed lung which are airless, firm, and bluish- 
red in color. The collapse has resulted from occlusion of the 
bronchus, and closely resembles consolidation ; but it can, as 
a rule, be overcome when inflation is practised by means of a 
blowpipe inserted in the supplying bronchus. 

Microscopic examination reveals an exudate in the terminal 
bronchi and air-cells, which is composed of leucocytes and des- 
quamated epithelium in various stages of degeneration. 
The walls of the bronchi are also infiltrated with leucocytes. 

When compared with croupous pneumonia, the contrast is 
striking. In the latter the lung is involved en masse ; the con- 
solidation is distinctly granular, and is composed of red blood- 



208 DISEASES OF THE RESPIRATORY SYSTEM. 

corpuscles, white blood-corpuscles, fibrin, and diplococci ; the 
lining epithelium is but slightly involved ; and the walls of the 
bronchi are not infiltrated with leucocytes. 

Terminations. — (1) Resolution ; the exudate undergoes 
fatty degeneration and is removed by absorption or expectora- 
tion. (2) Tuberculosis. Termination in phthisis is quite com- 
mon ; doubtless in many cases the disease was primarily tuber- 
culosis, and in others the exudate became a good soil for the 
development of tubercle bacilli. (3) Abscess or gangrene; 
these terminations are rare except in pneumonias resulting 
from aspiration. 

Symptoms. — The symptoms are often masked by the pri- 
mary disease. The onset is usually gradual, and is character- 
ized by prostration, cough, and fever. The last is moderately 
high and very irregular (101°-104°). The dyspnoea is 
marked, and the respirations are rapid — 50 to 80 per minute ; 
the pulse is greatly accelerated — 120 to 180 per minute; 
cough is painful and accompanied by a muco-purulent ex- 
pectoration which is rarely blood-streaked. The face is usu- 
ally pale and anxious, and the lips blue. 

Physical Signs. — As the areas of consolidation are gene- 
rally small and scattered, the physical signs are not marked. 

Inspection reveals evidences of dyspnoea, — lividity, playing 
of the nostrils, prominence of the sterno-cleido-mastoids, and 
retraction of the base of the chest. 

Palpation usually gives negative results. 

Percussion may reveal areas of dulness in one or both lungs. 

Auscultation reveals fine sibilant (whistling) or subcrepitant 
rales, and areas over which the breathing is tubular, or bron- 
chial. 

Prognosis. — The folio wing table will show the clinical 
differences between catarrhal and croupous pneumonias : — 



CATARRHAL PNEUMONIA. 



209 





Catarrhal Pneumonia. 


Croupous Pneumonia. 


Age 


Most common form in chil- 
dren. 
Usually secondary to bron- 


Not common in children. 


Cause .... 


A primary disease excited 




chitis. 


by the diplococcus. 


Onset .... 


Gradual, a chill generally 
absent. 


Abrupt onset with a chill. 


Fever .... 


Moderately high, very ir- 


High, regular, and ending 




regular, and ending by 


by crisis at the eighth or 




lysis after an indefinite 


ninth day. 




period. 




Expectoration . 


Muco-purulent. 


" Rusty," translucent, and 
tenacious. 


Physical Signs . 


A bilateral disease. Phy- 


A unilateral disease. Phy- 




sical signs are indistinct 


sical signs are distinct 




and indicate scattered 


and indicate a large and 




areas of consolidation. 


uniform consolidation. 



Acute Phthisis. — In this disease there is a tuberculous 
broncho-pneumonia which is difficult to distinguish from sim- 
ple broncho-pneumonia. A family history of tuberculosis, an 
extensive involvement of the apices, bubbling rales indicating 
softening, long duration, and bacilli and elastic fibres in the 
sputa are the diagnostic phenomena of phthisis. 

Bronchitis. — In simple bronchitis the fever is not high, the 
dyspnoea is rarely marked, prostration is usually absent, and 
there are no physical signs indicating consolidation. 

Capillary Bronchitis always precedes catarrhal pneumonia, 
and the diagnosis of the two is often impossible. The absence 
of physical signs indicating consolidation is the only diagnostic 
factor. 

Prognosis. — Always guarded. In the very young, very 
old, and debilitated the disease is commonly fatal. Many 
recover from the pneumonia following the infectious fevers. 
Aspiration-pneumonia is commonly fatal. The mortality is 
difficult to estimate, for acute phthisis is often diagnosed 
catarrhal pneumonia ; it is probably greater than in croupous 
pneumonia, and varies from 30 to 60 per cent. The duration 
is from one to three weeks ; a longer duration would suggest 
tuberculosis. 

Treatment. — The disease can often be prevented by care- 
fully protecting patients suffering from bronchitis and infec- 
14 



210 DISEASES OF THE RESPIRATORY SYSTEM. 

tious fevers. In the latter it is also essential that the naso-pha- 
rynx should be kept clean with some mild antiseptic solution. 

The room should be well ventilated, but free from draft, 
and the temperature should be kept uniformly at 70°. A 
moist atmosphere is desirable, and an apparatus for producing 
steam may be improvised. Tincture of iodine may be applied 
locally, and the chest enveloped in a cotton jacket. 

The diet should be liquid or semi-liquid, and may include 
milk, junket, koumiss, eggs, broths, and beef-juice. Stimu- 
lants, wine or brandy, are usually required to combat the 
extreme prostration. 

At the onset a laxative should be administered, and calomel 
may be selected (gr. J every hour until it operates). 

Stimulating expectorants are nearly always indicated, and 
chloride of ammonium, carbonate of ammonium, squills, or 
senega may be employed. 

Jfc Ammon. chloridi, gr. 1 ; 
Spt. aetheris nitrosi, f^ss ; 
Syr. senegae, f^iiss ; 

Tinct. cardamom, comp. el aquae, aa q. s. ad f^ij. 

— M. 
Sig. — A teaspoonful every two or three hours to a child of three 
years. 

Or— 

]£. Ammon. carb., gr. xxiv ; 
Syr. tolu., f^vj; 
Spt. vim gal., fspij ; 
_ Syr. senegas, f ^iijss ; 

Syr. acaciae, q. s. ad fgiij.— M. 

(Goodhart and Stare.) 
Sig. — Teaspoonful every two hours to a child of two or three years. 

Strychnia is often invaluable as a respiratory and cardiac 
stimulant ; for an adult, gr. -J^ may be given three or four 
times daily. 

The accumulation of mucus in the bronchial tubes, indicated 
by extreme cyanosis, a weak pulse, and bubbling rales, will 
call for an emetic; wine of ipecac (3j-lss), or apomorphia 
(for an adult gr. -jL-) may be selected. Nervous symptoms — 
restlessness, delirium, etc. — will often be relieved by a cold 
pack or by a cold bath. Hvoscine, bromide of potassium, or 



CHRONIC INTERSTITIAL PNEUMONIA. 211 

chloral in small doses may be required. In children the fol- 
lowing suppository is often very efficient : — 

I£ Pulv. assafoetidse, gj ; 

Quininae sulph., gr. xxx ; 

01. theobromine, q. s.— M. (Pepper.) 
Ft. in suppos. No. xii. (Child's size.) 
Sig.— One every three or four hours for a child of five years. 

In delayed resolution counter-irritants should be applied, to 
the affected areas, and iodide of potassium should be adminis- 
tered internally. 

Convalescence must be guarded; tonics like cod-liver-oil, 
iron, arsenic, and hypophosphites are useful restoratives. A 
change of scene is desirable. 

CHRONIC INTERSTITIAL PNEUMONIA. 

(Cirrhosis of the Lung, Chronic Pneumonia, Pulmonary- 
Induration. ) 

Definition. — A chronic disease of the lung, characterized 
by an overgrowth of fibrous tissue. 

•Etiology. — It is a rare sequel of croupous pneumonia. It 
is commonly found associated with tubercles in fibroid phthisis. 
The overgrowth of connective tissue is sometimes induced by 
an old fibrinous pleurisy. It may be an expression of syphilis. 
It arises primarily from the constant inhalation of irritating 
dusts, as stone-dust (Chalicosis), coal-dust (Anthracosis), 
metal-dust (Siderosis). 

Pathology. — When the thorax is opened the lung is found 
retracted and the heart displaced. The organ is tough, firm, 
and more or less airless. Section shows an overgrowth of 
fibrous tissue, and usually inflammation and considerable dila- 
tation of the bronchi. 

Symptoms. — Moderate dyspnoea and chronic cough ; the 
expectoration may be slight, but often it is profuse, and fetid 
from having been retained in bronchiectatic cavities. There 
is no fever, and the general health may be well preserved for 
many years. 

Physical Signs. — Inspection reveals retraction of the 
affected side and displacement of the apex-beat. 



212 DISEASES OF THE RESPIRATORY SYSTEM. 

Percussion often yields dulness ; but over saccular dilata- 
tions of the bronchi there may be hyper-resonance. 

Auscultation. — The vocal resonance is increased and the 
breathing: is often bronchial or cavernous. 

Diagnosis. Fibroid Phthisis. — -Involvement of both lungs, 
bacilli in the sputa, and fever would indicate fibroid phthisis. 

Prognosis. — Incurable. The duration is from ten to twenty 
years. 

Treatment. — Palliative. It consists in good hygienic 
regulations and the use of remedies directed to the bronchi- 
ectasis. 



GANGRENE OF THE LUNG. 

Definition. — A putrefactive necrosis of the lung. 

Etiology. — Gangrene is not a primary condition, but is 
secondary to some inflammatory disease of the lung. It is ex- 
cited by the entrance of bacteria of putrefaction, but unless the 
system is considerably reduced in vitality the tissues, even 
though diseased, show wonderful resistance, and escape putre- 
faction. 

Pneumonia, especially aspiration-pneumonia, phthisis, pres- 
sure of morbid growths, bronchiectasis, abscess, and hemor- 
rhagic infarction following embolism of the pulmonary artery 
are the predisposing pulmonary conditions ; and Bright\s dis- 
ease, alcoholism, the infectious fevers, and particularly diabetes, 
by lowering the vitality, render these conditions operative. 

Pathology. — The process may be circumscribed or diffuse, 
most frequently the former. The affected part is converted 
into a greenish-black, soft mass, having an extremely fetid odor. 
When the softened material has been expectorated there is left 
behind a cavity with ragged walls, containing a foul-smelling 
liquid. The tissues around the cavity are inflamed and o?de- 
matous. 

Symptoms. — The symptoms of gangrene are associated with 
the original disease. Cough, dyspnoea, moderate fever, and 
great prostration are generally present. 

The expectoration is characteristic ; it is profuse, and has a 
penetrating offensive odor. When allowed to stand in a glass 



ABSCESS OF THE LUNG. 213 

vessel it separates into three layers : a frothy layer on top, a 
serous layer in the middle, through which hang strings of pus, 
and at the bottom a layer of reddish-green purulent material. 
Altered blood may give it the appearance of prune-juice. 
Microscopically it contains shreds of tissue, crystals of fatty 
acids, crystals of hsematoidin, and all sorts of bacteria. 

Physical examination may reveal bubbling rales, and later 
cavernous breathing, pectoriloquy, and localized tympany on 
percussion. 

Prognosis. — Grave. Death usually results from exhaus- 
tion, but occasionally from hemorrhage or pyo-pneumothorax. 

Treatment. — Nutritious food, and quinine, strychnia, and 
alcoholic stimulants will be required to support the system. 

The offensive odor of the breath may be destroyed by car- 
bolic acid (gr. j every four hours) internally, or by inhalations 
of carbolic acid or creasote. Turpentine (Xv every three 
hours) has been recommended as a stimulant and antiseptic. 
When the patient's strength will permit, surgical interference 
offers the best chance of cure. 

ABSCESS OF THE LUNG. 

Definition. — Circumscribed suppuration of the lung. 

Etiology. — (1) It is rarely a sequel to pneumonia. (2) 
Multiple abscesses are often embolic, and result from pyaemia. 
(3) Foreign bodies in the lungs — something swallowed or an 
hydatid cyst — may excite suppuration. (4) External abscesses 
sometimes rupture into the lung, as an empyema, hepatic ab- 
scess, or suppurating mastitis. 

Symptoms. — High and irregular fever, rigors, sweats, and 
pallor indicate suppuration. Dyspnoea, cough, and purulent 
offensive sputa containing shreds of lung tissue are the pul- 
monary symptoms. Physical examination may reveal bub- 
bling rales, and later, cavernous breathing and pectoriloquy. 
Multiple embolic abscesses are rarely recognized during life. 

Prognosis. — Many cases following pneumonia and the 
rupture of external abscesses into the lung recover. Embolic 
abscesses generally prove fatal. 



214 DISEASES OF THE RESPIRATORY SYSTEM. 

Treatment. — Nutritious food and quinine, strychnia, and 
alcoholic stimulants will be required to support the system. 
The abscess should be opened and drained, as the pleural sac 
is in empyema. 

OEDEMA OF THE LUNGS. 

Definition. — An effusion of serous fluid into the air- 
vesicles and into the interstitial tissue of the lungs. 

Etiology. — Pulmonary oedema is a common cause of 
death in many acute and chronic diseases which end by heart- 
failure and the accumulation of blood in the lungs. 

It is frequently noted in the course of Bright's disease and 
cardiac disease. 

A local pulmonary oedema is often found around pulmonic 
consolidations, abscesses, and infarctions. 

Pathology. — The lungs, especially the dependent portions, 
are heavy, red in color, and boggy to the feel. When the 
affected portion is incised and pressure is made, an abundant 
blood-stained, frothy serum exudes. 

Symptoms. — Extreme dyspnoea ; rapid, labored breathing ; 
cough with frothy, blood-stained expectoration; cyanosis; and 
cold extremities. 

Physical Signs. Inspection reveals evidences of dyspnoea — 
sitting posture and prominence of the auxiliary muscles of 
respiration. 

Percussion. — Dulness over the bases. 

Auscultation. — Feeble respiratory murmur ; subcrepitant or 
bubbling rales. 

DiAGNosrs. Pneumonia. — The absence of chill, of fever, 
of " rusty" tenacious sputa, of pain, and of signs indicating 
consolidation will indicate oedema. 

Capillary Bronchitis. — The fever and muco- purulent expec- 
toration will serve to distinguish bronchitis from oedema. 

Prognosis. — Always grave. It is often a final symptom 
of some pulmonary disease. When not advanced, and the 
conditions are favorable, recovery may follow. 

Treatment. — When there is much cyanosis, and the 
patient's strength will permit it, the application of wet cups 



PULMONARY COLLAPSE. 215 

to the chest or bleeding from the arm is of great value. Hot 
fomentations should be applied to the chest. Hydragogue 
cathartics are indicated. Epsom salts in concentrated solu- 
tions, or elaterium (gr. J), may be selected. Cardiac stimulants 
like ether, alcohol, ammonia, digitalis, and especially strychnia, 
are required, and may be given hypodermicallv. 

fy Strychnin, sulph.. gr. j ; 
Aquae destillat., f^j. 
Solve et sig. — 15 minims hypodermically every three or four hours. 

Caffeine is a useful diuretic, and cardiac and respiratory 
stimulant. 

Ijc Caffein., 3J ; 

Sodii benzoat., 3jss. — M. 
Ft. in chart. No. xii. 
Sig. — One every two or three hours 

PULMONARY COLLAPSE. 

(Atelectasis.) 

Definition — An absence of air from a portion of the lung. 

Etiology. — It may be congenital and result from deficient 
respiration ; in these cases the dependent portions of both 
lungs are commonly affected. Acquired atelectasis results 
from occlusion of a bronchus by a foreign body or a plug of 
mucus, as in capillary bronchitis ; or from compression of the 
lung by a tumor or pleural effusion. 

Symptoms. — When a large area is collapsed in some pre- 
existing disease like capillary bronchitis, there is an abrupt 
increase in the dyspnoea and cyanosis, without a corresponding 
rise of temperature. Physical examination gives negative 
results except over extensive collapse, which may give dulness 
on percussion and weak breathing on auscultation. 

Prognosis. — This depends upon the extent of collapse and 
the gravity of the pre-existing disease. 

Treatment. — In congenital atelectasis apply alternately 
hot and cold sponges to the spine ; keep up the external tem- 
perature. If these measures fail, gently inflate the lung with 
a catheter. 

In the acquired varieties direct remedies to the original 



216 DISEASES OF THE RESPIRATORY SYSTEM. 

disease. Administer cardiac and respiratory stimulants like 
ammonia, and produce emesis with ipecac or alum. 

PULMONARY TUBERCULOSIS. 

(Phthisis, Pulmonary Consumption.) 

Definition. — A specific inflammatory disease of the lungs, 
caused by the bacillus tuberculosis; characterized anatomically 
by a cellular infiltration which subsequently caseates, softens, 
and leads to ulceration of the lung tissue; and manifested 
clinically by wasting, exhaustion, fever, and cough. 

Etiology. — (1) Residence in low, damp, and badly-drained 
localities. (2) Heredity (important). (3) Age; all ages, but 
especially between twenty and thirty years. (4) Occupations 
which necessitate the breathing of impure air and the inhala- 
tion of irritants like coal-dust, stone-dust, iron-filings, etc. 

(5) Catarrhal inflammation and traumatism of the lungs. 

(6) Physique. (7) General diseases which lower the vitality, 
as diabetes, hepatic cirrhosis, and typhoid fever. 

The exciting cause is the bacillus tuberculosis, which gains 
entrance (1) by direct parental transmission (very rare) ; (2) by 
inhalation, the dust of dried sputum being commonly the 
medium of contagion ; (3) through infected food, as the milk 
and meat of tuberculous cattle. 

Varieties. — (1) Chronic ulcerative phthisis. (2) Acute 
phthisis. (3) Fibroid phthisis. 

Pathology. — The bacillus tuberculosis is a very minute 
rod, about one-fourth or one-half as long as a red blood- 
corpuscle, and often slightly bent and beaded. Its detection 
depends on the power of the stained bacillus to resist the de- 
colorizing effects of acids. For satisfactory examination a 
one-twelfth oil-immersion lens is required. 

The lodgment of bacilli in the terminal bronchioles of the 
apex excites a proliferation of the fixed cells, which become 
more or less polvgonal in shape. The new cells are termed 
epithelioid, and frequently contain bacilli. Giant cells are often 
formed by a fusion or overgrowth of these cells. 

This aggregation of new cells acts as an irritant and is soon 
surrounded by a wall of leucocytes, the whole forming a gray, 



- 

PULMONARY TUBERCULOSIS. 217 

translucent mass — the gray tubercle of Laennec. In a short 
time the bacilli excite a coagulation-necrosis which starts in 
the centre, spreads to the periphery, and converts the tubercle 
into a yellow, cheesy mass — the yellow tubercle of Laennec. 
The degenerated tubercles fuse and form the uniform cheesy 
masses so commonly observed at the autopsy. At this stage 
one of two things may occur: The mass may soften, break 
into a bronchial tube, and leave behind a cavity with ulcerat- 
ing walls, or it may become encapsulated by an overgrowth of 
connective tissue and subsequently calcified. In addition to 
the specific process other secondary changes are noted. The 
lung tissue in the neighborhood of the tuberculous deposits is 
often the seat of a true pneumonic inflammation ; the connective 
tissue is always more or less proliferated ; the bronchial tubes 
are inflamed ; and the pleurae over the affected areas are nearly 
always adherent. 

Chronic ulcerative phthisis usually begins at the apices. 

Acute phthisis has been termed phthisis florida, cheesy pneu- 
monia, and chronic catarrhal pneumonia, but the process is 
invariably tuberculous. From extreme vulnerability of the 
tissues a lobe or whole lung, or even both lungs, are rapidly 
infiltrated, and death results in from a few weeks to a few 
months. 

In some cases the lung is solidified by a dense yellowish- 
gray infiltration composed of closely-aggregated tubercles ; in 
others the consolidation appears in more or less discrete 
patches which have had their origin in the smaller bronchial 
tubes ; in a third form one or both lungs are studded with 
discrete tubercles, many of which are still gray and trans- 
lucent. 

In fibroid phthisis the tissues appear to be resistant, and 
the process is limited by an overgrowth of connective tissue 
which forms dense bands around the tuberculous foci. This 
form lasts many years. 

Chronic Ulcerative Phthisis. Symptoms. — The onset is 
usually insidious and marked by pallor, gastric disturbance, 
loss of flesh and strength, and by a dry, hacking cough which 
is especially noted in the morning. From some undue ex- 
posure, -the cough is often aggravated, and to this obstinate 



218 DISEASES OF THE RESPIRATORY SYSTEM. 

"cold" the disease is usually attributed. In some cases, the 
symptoms appear abruptly with hemorrhage or an acute 
pleurisy. 

Slight fever and acceleration of the pulse are early symptoms 
of great diagnostic import. The temperature is marked by an 
evening exacerbation, during which the face is flushed, the 
eyes bright, and the mind animated. As the disease ad- 
vances the cough becomes troublesome and the expectoration 
more abundant. In well-developed cases the expectoration is 
greenish in color, is in coin-shaped plugs (nummular), is heavy 
and sinks in water, is often blood-streaked, and on microscopic 
examination is found to contain bacilli and fibres of elastic 
tissue. 

Phthisis is in itself not a painful disease, but the associated 
dry pleurisy ofteu causes much suffering. Haemoptysis occurs 
at all stages, but the profuse hemorrhages occur late. The 
blood is bright red in color, frothy, and mixed with mucus. 
Dyspnoea is not a marked symptom, and its absence is doubt- 
less due to the gradual development of the disease. Profuse 
sweating during sleep is a troublesome feature of advanced 
phthisis. 

The final stage is characterized by extreme emaciation, 
weakness, pallor, high remittent or intermittent fever, and 
oedema of the feet. The mind is usually clear, and peculiarly 
hopeful to the end. 

Physical Sig^s. Inspection. — The chest is usually long 
and flat ; the spaces above and below the clavicles are sunken ; 
the scapulae are prominent ; and the ribs are oblique. 

There may be flattening or less expansion over one apex. 

Palpation. — Diminished expansion and increased vocal fre- 
mitus. 

Percussion. — Dulness, as a rule ; this is noted earliest above 
or below the clavicles, in the supraspinous fossae, between the 
scapulae, or in front near the sternal border. 

A cavity, or vomica, yields tympany, or a " cracked-pot" 
resonance. The latter can be more clearly demonstrated when 
the ear is placed near the patient's open mouth. 

Auscultation. — In the early stage respiration may be inaud- 
ible over the affected area. Later the breathing is harsh 



PULMONARY TUBERCULOSIS. 219 

and the expiration prolonged and high-pitched (bronchial). 
The vocal resonance is increased. Crackling rales are usually 
audible, and are produced by liquid in the small tubes. If 
not present, coughing will usually develop them. Ausculta- 
tion over cavities may detect cavernous or amphoric breathing, 
pectoriloquy, and large gurgling rales. 

Anomalous Physical Signs. — The vocal fremitus is 
diminished when there is much pleural thickening. Normal 
resonance or hyper-resonance may replace dulness when there 
is much emphysema between small tuberculous foci. Weak 
breathing may replace bronchial or cavernous when the tubes 
or cavity are filled with muco-pus. The signs of cavity are 
sometimes produced by consolidation in the neighborhood of a 
large bronchus. 

Acute Phthisis. — Clinically this form resembles pneumonia, 
and is marked by a chill, high fever, rapid pulse, dyspnoea, 
sputum at first rusty and then purulent, flushed face, profuse 
sweats, and the signs of consolidation. Instead of ending by 
crisis at the eighth or ninth day as an ordinary pneumonia, 
the symptoms grow rapidly worse, signs of softening appear, 
the sputum shows bacilli and elastic fibres, and death results 
in from a few weeks to a few months. 

Fibroid Phthisis. — This is a disease of long duration. It is 
characterized by very gradual loss of flesh and strength and 
by an abundant muco-purulent expectoration, which is at 
times fetid from being retained in dilated bronchi. Dyspnoea, 
sweating, and fever are slight. There is very marked retrac- 
tion on the affected side from the shrinking of the fibrous tis- 
sue ; with this exception the physical signs are similar to those 
of ulcerative phthisis. 

Complications of Phthisis. — Haemoptysis ; pneumonia ; 
pleurisy ; pneumothorax ; stomatitis ; obstinate vomiting induced 
by cough ; diarrhoea; amyloid degeneration of the viscera; fistula 
in ano (tuberculous); and secondary tuberculosis of other organs, 
especially the larynx, cerebral meninges, and peritoneum. 

Diagnosis. — Fever, cough, emaciation, signs of consolida- 
tion, bacilli and elastic fibres in the sputum are the diagnostic 
phenomena. 



220 DISEASES OF THE RESPIRATORY SYSTEM. 

Prognosis. — Generally unfavorable, though the disease is 
not incurable. The accidental discovery of calcified tubercles 
at autopsies furnishes abundant evidence of spontaneous cure. 
Many improve and a few recover under well-directed treatment. 

A strong hereditary tendency, a bad physique, high fever, 
advanced consolidation, involvement of both lungs, even if 
slight, unfavorable surroundings, and, it might be added, a 
slender purse, render the prognosis extremely grave. 

Treatment. Preventive. — Eecognizing the infectious 
nature of the disease, the following prophylactic measures 
should be observed : Sputa of consumptives should be received 
in suitable vessels containing antiseptic solutions, and subse- 
quently destroyed. Cattle should be rigidly inspected, and 
tuberculous meat, and milk of tuberculous cows declared un- 
marketable. Phthisical mothers should not nurse their off- 
spring. The healthy should not sleep in apartments occupied 
by those affected. 

Personal Hygiene. — Good food, fresh air, frequent bathing, 
avoidance of exposure, graduated exercise, residence in an 
elevated locality, a dry, well-ventilated house, and plenty of 
sleep and recreation. 

Curative Treatment. — This involves two objects : (1) The 
strengthening of the patient's vitality and resisting power. 
(2) The destruction or disabling of the tubercle bacilli. 

General Health. — The diet should be carefully regulated. 
Nutrients like cod-liver oil (3ij — 3iv two hours after meals), 
malt, and hypophosphites are often very useful. Mineral acids 
and bitters may be required to stimulate digestion. Iron, 
quinine, and arsenic are sometimes indicated ; the last, when 
well borne, often exerts a decidedly favorable influence. Alco- 
hol in many cases is of great value, but the danger of inducing 
the habit must be borne in mind. Beer, porter, ale, and wine 
are usually the most desirable preparations. So long as alcohol 
stimulates the appetite, lowers the temperature, and strengthens 
the pulse it does good. Its results should be carefully noted, 
and any untoward effects will call for its immediate withdrawal. 

Change of Climate. — ,This offers to many patients the 
greatest hope of cure. As a rule, a high altitude should be 
selected ; the atmosphere should be dry and the temperature 



PULMONARY TUBERCULOSIS. 221 

equable. Personal experience must decide the question of 
temperature ; generally, patients who feel better in summer 
will do well in a warm climate, and vice versa. The physician 
should have some knowledge of the locality, which should 
afford ordinary conveniences, without being too crowded with 
sufferers similarly afflicted. 

In selected cases, a sea voyage is often very useful. Accord- 
ing to Douglas Powell, it is most suitable to patients in the 
early stages, who have been previously healthy, who have 
overworked nervous systems, and in whom the disease is 
more or less quiescent. 

Patients in advanced phthisis should not be sent far from 
home. 

Specific Treatment. — The injection of iodine, carbolic acid, 
etc., into phthisical lungs, as recommended by Mosler, Thomp- 
son, and Pepper, has not given encouraging results. The 
rectal injection of sulphide of hydrogen, as recommended by 
Bergeon, has fallen into disuse. Koch's tuberculin has, for 
the most part, been negative or deleterious in its effect. Of 
all the special remedies, creasote alone continues to hold its 
prominent position in the therapy of phthisis. It may be 
given in pill, in emulsion of cod-liver oil, or with wine. 

J$l Creasoti, TTlxv ; 
Olei morrhuge, f^iij ; 
Calcii et sodii hyposphos. , 3ss ; 
Olei gaultherige, TTLxx ; 
Acacise, q. s. 
Aquae, q. s. ad fjvj. — M. 
Sig.— A tablespoonful two hours after meals. 

Or— 

J$l Creasoti, TTlxv ; 

Tinct. gentian., TTLxij ; 
Spt. vini rect., f^vj ; 
Vini xerici, f^vj.— M. (Fraentzel.) 
Sig. — A teaspoonful thrice daily. 

Creasote is often valuable in inhalations. 

I£ Creasoti, 

Spt. chloroform i, 
Alcoholis, aa ^ss. — M. 
Sig.— Ten to twenty drops in the inhaler several times daily. 



'222 DISEASES OF THE RESPIRATORY SYSTEM. 

Symptomatic Treatment. Cough. — Syrups should be avoided 
as far as possible, and cough alleviated by inhalations of wine 
of ipecac, creasote, benzoin, or terebene. 

Tar, terebene, and eucalyptus may be employed internally. 
Cough • associated with the expectoration of much offensive 
material should not be checked. 

A cold bed often leads to cough and a wakeful night ; in 
these cases the bed should be warmed before it is occupied. 
Hot applications to the chest and a hot drink on retiring 
sometimes insure rest. 

The following mixture is very efficient in the cough of 
phthisis : — 

]£. Codeinse sulph., gr. iv ; 

Acid, hydrocyanic, dil., TTLxxxij ; 
Syr. tolu., 131J.— M. (Da Costa.) 

Sig. — A teaspoonful three or four times daily. 

Sweating.— Atropine (gr. T ^), picrotoxin (gr. gViro); gallic 
acid (gr. x), agaricinic acid (gr. i-J), sulphonal(gr. iij-viij), or — 

J$l Atropin. sulph., gr. ^ ; 
Acid, sulph. aromat., ^ij ; 
Aquae rosae, q. s. ad f^j.— M. 
Sig. — Twenty to thirty drops at bedtime, and repeated if neces- 
sary. 

Sponging with alum and whiskey is sometimes very efficacious. 

Haemoptysis. — When profuse, ice may be held in the mouth 
and swallowed slowly. The fluid extract of ergot (gtt. xx- 
xxx) and morphia (gr. \) should be given hypodermically. 
The internal administration of gallic acid and other astrin- 
gents is of little value. The application of a temporary liga- 
ture to one or more of the members hinders the flow of blood 
in the veins, and may materially aid in checking the bleeding. 

\Yhen the hemorrhage is more or less continuous, but not 
profuse, the fluid extract of hamamelis (3ij-3iij) or pills of 
acetate of lead and opium are efficient remedies. 

Diarrhoea. — Eest ; liquid diet; subnitrate of bismuth in 
large doses, or pills of nitrate of silver and opium. 

I£ Bismuth, subnit., gvj ; 

Salol, gr. xxiy ; 

Morphin. sulph., gr. j. — M. 
Ft. in chart. Xo. xii. 
Sig. — One powder every three hours. 



PLEURISY. 223 

Pyrexia. — The patient must rest. Continuous high fever 
will call for quinine, antipyrin, antifebrin, or thallin. Spong- 
ing with alcohol and cool water, equal parts, is a desirable 
method of reducing fever. 

Pain. — When severe, administer opium and apply to the 
affected side adhesive straps, hot applications, dry cups, or 
iodine. 

PLEURISY. 

(Pleuritis.) 

Definition. — Inflammation of the pleura. 

Varieties. — According to cause, it may be divided into 
primary or secondary; according to extent, into unilateral, 
bilateral, or local ; according to time, into acute or chronic ; 
and according to the exudation, into sero-fibrinous, fibrinous, 
or purulent. 

Etiology. — Pleurisy may be : (1) Idiopathic, arising from 
exposure to cold and wet. (2) Traumatic. (3) Secondary to 
inflammatory diseases of adjacent viscera, as pneumonia and 
phthisis. (4) Secondary to some general morbid process, as 
rheumatism, Bright's disease, tuberculosis, and the infectious 
fevers. (5) Tuberculous. (6) Cancerous (rare). 

Pathology. — In the early stage the membrane is red, 
sticky, lustreless, and covered with a thin film of lymph ; if 
the process now ceases, the condition is termed dry pleurisy. 
If, however, the inflammation continues, an exudate is formed 
which may be: (1) Sero-fibrinous, (2) fibrinous, or (3) puru- 
lent (empyema). In the sero-fibrinous form there is little 
lymph, the exudate being mainly composed of straw-colored 
serum (a few ounces to several pints) which in favorable 
cases is gradually absorbed. In large effusions the adjacent 
organs are displaced and the lungs are compressed. In the 
fibrinous form serum is scant and the membrane is cov- 
ered with a butter-like exudate which subsequently organizes 
and unites more or less closely the pleural surfaces, causing 
adhesive pleurisy. A liquid effusion, which is circumscribed 
and confined to pockets formed of adhesions, is termed saccu- 
lated pleurisy. 



224 DISEASES OF THE RESPIRATORY SYSTEM. 

In the purulent form the sac is more or less filled with 
greenish-yellow pus. Purulent pleurisy, or empyema, is com- 
mon in children ; it frequently follows the infectious fevers ; 
it is often secondary to a sero-fibrinous pleurisy ; it results 
from the rupture of purulent accumulations into the pleura, 
as by a tuberculous cavity ; and finally, it may be due to 
traumatism, as a penetrating wound or fracture of the ribs. 

A purulent effusion left to itself may kill by sepsis, may 
become inspissated and encysted (rare), or may perforate into 
the bronchi, into neighboring organs, or externally. 

Hemorrhagic Pleurisy. — A bloody effusion is observed in 
tuberculous and cancerous pleurisies and in pleurisy which is 
associated with scurvy, grave anaemia, and other cachectic 
states. 

An effusion of any kind remaining unabsorbed constitutes a 
chronic pleurisy. 

Symptoms. Acute Pleurisy. — Chilliness ; a stabbing pain 
or stitch in the affected side, intensified by deep breathing 
and by cough; moderate fever (101°— 103°); cough short, 
dry, and partially suppressed ; the face is generally pale and 
anxious ; and the patient usually lies on the affected side. 

AVhen the effusion forms, the inflamed surfaces separate, so 
that the pain becomes less ; but dyspnoea rapidly develops, and 
the respirations are of a short, jerky character. 

Physical Signs. First Stage. — Less expansion on the 
affected side on account of the pain ; occasionally a friction- 
fremitns on palpation, and a harsh to-and-fro friction-rub on 
auscultation. 

Stage of Effusion. Inspection. — Immobility and bulging of 
the intercostal spaces on the affected side. The apex-beat is 
displaced upwards, and to the left or right according to the 
pleura affected. 

Palpation. — Immobility and diminished vocal fremitus. 

Percussion. — Dulness gradually rising as the fluid increases. 
The upper line of dulness is not horizontal, but is curved and 
rises higher posteriorly. In moderate effusions the level of 
dulness often changes with the position of the patient. Above 
the effusion percussion gives a tympanitic note which has been 
termed Skoda's resonance. 



PLEURISY. 225 

Auscultation. — The respiratory sounds are weak and dis- 
tant ; they may have a tubular or bronchial quality. The 
vocal resonance is usually diminished or absent, but occa- 
sionally bronchophony, or its modification segophony (a bleating 
sound), is heard over moderate effusions. 

Mensuration. — The affected side is sometimes an inch or 
more larger than the sound one. 

After absorption of the effusion the friction-sound returns. 

Diagnosis. Pneumonia. — The severe chill, rusty expec- 
toration, high fever, marked dyspnoea, the fine crepitant rales 
which are heard only on inspiration, dulness not changing with 
the patient's posture, increased vocal fremitus, increased vocal 
resonance, loud bronchial breathing, and the absence of bulg- 
ing and of a displaced apex-beat, will serve to distinguish it 
from pleurisy. 

Pleurodynia, or Rheumatism of the Intercostal Muscles. — No 
fever, much diffuse tenderness, no friction-sounds, and no 
effusion. 

Purulent pleurisy is recognized by hectic symptoms — high 
and irregular fever, sweats, chills, and anaemia ; by the results 
of aspiration ; and sometimes by " pitting" from oedema of the 
surface. 

Fibrinous Pleurisy. — Pain is severe and continuous, the 
dulness is immobile, aspiration gives negative results, and later 
there is much retraction of the affected side. 

Tuberculous Pleurisy. — Tuberculosis is the most common 
cause of pleurisy which is apparently primary. It may be 
primary or secondary to pulmonary phthisis. It usually pre- 
sents the same symptoms as ordinary sero-fibrinous pleurisy, 
but it often develops insidiously, is frequently bilateral, and 
the effusion is apt to be bloody. These facts, together with 
the history, will usually indicate the diagnosis. 

Diaphragmatic pleurisy, or inflammation of the diaphrag- 
matic pleura, may present the following symptoms : Intense 
pain under the margin of the ribs, with tenderness on pressure ; 
thoracic breathing ; tenderness over the phrenic nerve, which 
is accessible between the two roots of the sterno-cleido-mastoid 
at the base of the neck ; hiccough ; and extreme dyspnoea. 
The physical signs are not marked. 
15 



226 DISEASES OF THE RESPIRATORY SYSTEM. 

Prognosis. — This depends largely on the character and 
the amount of effusion. In primary sero-fibrinous pleurisy, 
the prognosis is usually good, but that pleurisies, which are 
apparently primary, are often tuberculous, should always be 
borne in mind. In purulent pleurisy, the prognosis is grave, 
though recovery frequently occurs. 

In the fibrinous form, the prognosis is good, but if there 
has been much exudate, subsequent retraction and more or 
less impairment of the affected side are sure to follow. 

Treatment. — Absolute rest. Light diet. If the temper- 
ature is high and the pulse rapid, aconite may be administered 
in small doses. Quinine (gr. v thrice daily) will exert a favor- 
able influence. Pain may be so severe as to require morphia 
hypodermically. 

Local Applications. — When the pain is severe, leeches or 
wet-cups, followed by strapping of the chest, will give great 
relief. In other cases, mustard plasters, hot fomentations, or 
iodine may be applied. 

Serous Effusion. — Apply, frequently, small blisters. Iodide 
of potassium (gr. v thrice daily) may be employed for its ab- 
sorbent effect. 

Encourage diuresis with digitalis, caffeine, or acetate of 
potassium : — 

J$l Potass, acetat,, ^ss ; 

Iufus. digitalis, f^iij. — M. 
Sig. — Two teaspooufuls every three or four hours. 

Encourage catharsis with compound jalap powder (gr. xx- 
xxx) or Epsom salts. 

]£ Magnesii sulphat., ^iv-^vj. (Hay.) 
Div. in chart. No. viii. 

Sig. — One powder in two tablespoonfuls of water before food, and 
no fluids for some time afterwards. 

The effusion will require aspiration under the following 
conditions : (1) When it excites much dyspnoea ; (2) when it 
is very large, beyond the third or fourth rib ; (3) when it is 
purulent ; (4) when it remains unabsorbed after three or four 
weeks of careful treatment; (5) when it is bilateral, and the 
total amount is sufficient to fill one cavity. 



HYDROTHORAX — PNEUMOTHORAX. 227 

The Operation. — Anaesthetize a point in the seventh inter- 
space near the posterior axillary line and introduce the needle 
with a quick stroke along the upper border of the rili. The 
effusion should be drawn off slowly, and one or two pints re- 
moved according to the amount of the exudate. 

Coughing during the operation is an indication for the with- 
drawal of the needle. 

Empyema. — Make an incision in the fifth or sixth inter- 
space, outside of the mammary line, evacuate the pus and 
insert a drainage-tube. In some cases the excision of one or 
two ribs facilitates retraction and the obliteration of the 
pleural sac, which is essential to a cure. 

HYDROTHORAX. 

Definition. — Thoracic dropsy. 

Etiology. — it is always secondary, and may result from 
one of the causes of general dropsy, namely : Bright's disease, 
heart disease, emphysema or anaemia, or from the pressure of 
a tumor or aneurism upon the thoracic veins. 

Symptoms. — -Dyspnoea, cyanosis, and the physical signs of 
a pleural effusion. 

Diagnosis. — The history of the primary disease, the fact 
that the effusion is bilateral, the absence of pain, and the pres- 
ence of a fluid which is only slightly albuminous, and which 
shows little or no tendency to spontaneous coagulation, will 
serve to distinguish it from pleurisy. 

Treatment. — Remedies should be directed to the original 
disease. When there is much dyspnoea, aspirate. 

PNEUMOTHORAX. 

- Definition. — Air in the pleural sac. 

Etiology. — it may result from : (1) The rupture of the 
lung in health from a violent strain, or rupture in tuberculosis, 
abscess, emphysema, or gangrene. (2) Traumatism, as a pen- 
etrating wound or a fracture of the ribs. (3) The rupture of 
an empyema into the lung. 



228 DISEASES OF THE EESPIEATOEY SYSTEM. 

Pathology. — The adjacent viscera are displaced, and the 
lung is compressed. Even when air alone has escaped into 
the pleural sac, an effusion soon develops, so that in all cases 
the condition becomes a pneumo-hydrothorax or -pyothorax. 

Symptoms. — The onset is marked by a sharp pain, extreme 
dyspnoea, cyanosis, and symptoms of incipient collapse, namely, 
a fall of temperature, a weak rapid pulse, cold extremities, and 
pinched features. 

Physical Signs. Inspection. — Immobility, and bulging 
of the intercostal spaces. The apex-beat is usually displaced. 

Palpation. — Diminished vocal fremitus. 

Percussion. — A tympanitic note, varying in pitch with the 
intrathoracic tension. 

Effusion sinks to the base and yields dulness, the outline of 
which changes with the position of the patient. 

Auscultation. — The respiratory murmur and vocal resonance 
are usually absent, but when the opening in the lung remains 
patulous, amphoric breathing may be detected. When a silver 
coin is placed on the affected side and is struck with another, 
the auscultator detects a clear metallic sound (bell-tympany). 
When fluid is present, shaking the patient excites a splashing 
sound (Hippocratic succession). 

Diagnosis. A large Phthisical. Cavity. — This is usually 
located near the apex instead of the base : the surface is 
sunken, not prominent ; the heart is not displaced ; sueeus- 
sion-splash and bell-tympany are usually absent. 

Dilated Stomach. — This may give a tympanitic note over 
the left pulmonary base, and may simulate a pneumothorax ; 
but the tympanitic note is continued down into the abdomen, 
and the swallowing of liquid is distinctly audible over the 
base of the chest. 

Prognosis. — It is usually unfavorable, and often termi- 
nates fatally in a few hours or days. Recovery is possible, 
especially in traumatic cases. It often excites a pleural effu- 
sion and runs a chronic course. 

Treatment. — At the onset administer stimulants, and apply 
straps to the chest. The pain and distress must be relieved by 
morphia. 



HEMOTHORAX. 229 

When effusion forms it should be treated, according to its 
character, as a serous or a purulent pleurisy. 

HEMOTHORAX. 

(Haematothorax. ) 

Definition. — The effusion of blood into the pleural sac. 

Etiology. — Traumatism, rupture of an aneurism, or the 
erosion of bloodvessels by phthisical cavities or caries of the 
ribs. 

Symptoms. — Same as hydrothorax. 

Treatment. — When there is great dyspnoea the blood 
should be removed by aspiration or incision. 



ACUTE INFECTIOUS DISEASES. 



FEVER. 



Fever is an abnormal condition characterized by elevated 
temperature, quickened respiration and circulation, faulty se- 
cretions, aud increased tissue-waste ; and dependent upon a 
perversion of the physiological processes whereby the gene- 
ration and loss of heat are so balanced as to maintain a uni- 
form normal temperature. 

The Detection of Fever — There is only one sure way of 
detecting fever, and that is by means of the clinical ther- 
mometer. /The instrument may be placed in the axilla, 
mouth, rectum, or vagina. 

When the axilla is selected the following precautions must 
be observed : Wipe off the perspiration and dry the skin ; in- 
sert the bulb of the instrument deep in the armpit, and see 
that the arm is kept close to the side. The thermometer 
should be kept in position until the mercury maintains the 
same level for two minutes ; this will usually require in all 
about six or seven minutes. 

When the mouth is selected the bulb should he placed 
under the tongue and the lips kept closed. Hot and cold 
drinks recently taken mar the results. For obvious reasons 
the mouth should not be used in delirious patients. 

The rectum may be selected in children. The rectal tem- 
perature is about a degree higher than that of the axilla. 

Febrile Stages. — The course of all fevers is marked by three 
stages : (1) Invasion ; (2) fastigium, or stadium ; (3) defer- 
vescence, or decline. 

Invasion. — During this period the temperature gradually 
rises until it reaches its maximum. 
( 230 ) 



FEVER. 231 

Fastigium. — In this period, though there may be marked 
variations, the temperature shows a tendency to touch again 
and again its highest point. 

Defervescence. — In this period the temperature gradually 
falls until it reaches the norm. 

Terminations of Fever. — Fever terminates by lysis or 
crisis. 

Lysis. — The temperature falls slowly by slight gradations 
until it reaches the norm. 

Crisis. — The temperature falls suddenly, often four or five 
degrees in twelve or twenty-four hours. 

The Degree of Pyrexia. — The following is Wunderlich's 
classification of febrile temperatures : — 

1. Subfebrile, temperature 99.5°-100.4°. 

2. Slightly febrile, temperature 100.4°-101.3°. 

3. Moderately febrile, temperature 101.3°-103.1°. 

4. Decidedly 'febrile, temperature 103.1 °-104°. 

5. Highly febrile, temperature above 103.1° in the morning 

and above 104.9° in the evening. 

6. Hyperpyretic, temperature above 106°. 

Febrile Remissions. — All fevers show a diurnal variation. 
The maximum is usually reached at about 6 P.M. and the 
minimum at about 6 A.M. Sometimes these extremes are re- 
versed and the maximum is in the morning: and the minimum 
in the evening. The daily difference amounts to about 1°. 

Types of Fever. — According to the degree of the diurnal 
variation three types are recognized : — 

1 . Continued Fever. — The diurnal variation is slight, 1 °-l .5°. 
Typhus fever, pneumonia, and scarlet fever are examples of 
continued fevers. 

2. Remittent Fever. — The diurnal variation is marked, but 
the minimum temperature is still above the norm. Typhoid 
fever, remittent fever, and hectic fever are examples of this 
type. 

3. Intermittent Fever. — The diurnal variation is marked, and 
the minimum is normal or subnormal. The following fevers 
intermit : — 



232 ACUTE INFECTIOUS DISEASES. 

1. Intermittent fever (malaria). 

2. Relapsing fever. 

3. Hectic fever (often intermits, though generally remits). 

4. Charcot's intermittent (the peculiar fever associated with 

the impaction of gall-stones). 

Causes of Fever, — (1) Local inflammations excited by 
external causes, or the products of faulty metabolism 
(gout, rheumatism). (2) The presence of microorganisms or 
ptomaines in the body, as in typhoid fever, pyaemia, scarlet 
fever, etc. (3) Paralysis of the heat-centre, as in thermic 
fever. 

Symptoms of Fever. — Eise of temperature; rapid pulse; 
rapid respirations ; coated tongue ; anorexia ; constipation. 
The urine is scanty, high-colored, throws down a heavy sedi- 
ment, and may contain a trace of albumin. The gastric juice 
is deficient in acid. If the fever is long-continued, the body 
wastes. 

The Fulse-temperature ratio : — 
A temperature of 98.4° corresponds to a pulse of 70 

a u 10Q o « u u g _ 90 

" " 102° " " " 100-110 

a u 1Q4 o u u « 120-130 

Effects of Fever on the Tissues. — High and long-continued 
fever produces fatty and parenchymatous degeneration of the 
tissues. 

Treatment of Fever. — Absolute rest ; a cool, well-ventilated 
room ; liquid or semi-liquid diet. Slight fever will require no 
special remedies, but the patient may be made more comfort- 
able by sponging with cool water, or water and alcohol ; and 
by the use of such drugs as sweet spirits of nitre, acetate of 
ammonium, or neutral mixture. 

High fever is best controlled by the external application 
of cold ; this method includes sponging with cold water, the 
cold pack, and the cold bath. 

The Cold Pad:. — A rubber sheet is slipped under the patient, 
and the body is enveloped in a sheet wrung out in cold water, 



FEVER. 233 

which is allowed to remain until the temperature falls one or 
two degrees. 

The Cold Bath. — There are two methods of administering 
the cold bath. The first is to place the patient at once into 
water at 70° ; the other is to place him into water at 90° or 
80°, and then gradually cool it down to 75° or 70°. While in 
the water he should be subjected to gentle friction or massage. 
He should remain in the bath for fifteen or twenty minutes, 
after which he should be placed in a dry sheet and covered 
with a light blanket, "When the body is dry the damp sheet 
should be removed. A stimulant is sometimes required during 
or after the bath. 

Drugs may be employed to lower temperature, but the bath 
is preferable when it is feasible. Quinine, antipyrin, phe- 
nacetin, and antifebrin are the antipyretics most commonly 
employed. 

Period of Incubation. — The period elapsing between the en- 
trance of the poison and the development of symptoms. 

It varies considerably in the same disease, being more or less 
influenced by the susceptibility of the patient and the virulence 
of the contagion. The average period of incubation in the in- 
fectious fevers is as follows : — 

Typhoid fever: two to three weeks. 

Typhus fever: a few hours to two weeks. 

Measles: two weeks. 

Rotheln or rubella: ten to twelve days. 

Scarlatina : a few hours to a week. 

Smallpox: one to two weeks. 

Erysipelas : three to seven days. 

Diphtheria : two to ten days. 

Varicella : ten to fifteen days. 

Tetanus : a few days to two weeks. 

Mumps : two to three weeks. 

Yellow fever : from a few hours to a week. 

The date at which rashes appear in the various diseases:— 

Typhoid fever: seventh to the ninth day. 
Typhus fever: fourth or fifth day. 



234 ACUTE INFECTIOUS DISEASES. 

Smallpox : third or fourth day. 
Measles : third or fourth day. 
Scarlatina : first or second day. 
Rotheln or rubella: first or second day. 
Varicella : first day. 

Protection from Future Attacks. — Few diseases give abso- 
lute immunity from future attacks, but the following are fairly 
protective : — 

Typhoid fever : relapses are common, and second attacks some- 
times occur. 

Typhus fever : " second attacks very rare. 

Measles : second attacks uncommon ; what is supposed to be a 
second attack is usually rotheln. 

Rotheln : second attacks uncommon. 

Scarlatina: second attacks rare. 

Smallpox: second attacks occasionally occur. 

Mumps : second attacks rare. 

Yellow fever: second attacks rare. 

The following do not confer immunity : — 

Erysipelas : apparently predisposes to other attacks. 

Relapsing fever. 

Influenza. 

Diphtheria. 

Periodic Remission or Intermissions in the Fever. — Such 

remissions or intermissions occur in the following fevers : — 

Malarial fever : every day, every third day, or every fourth 

day, according to the type. 
Relapsing fever : intermissions occur at intervals of five or six 

days, and last five or six days. 
Smallpox : remission occurs on the third day. 
Measles: a distinct remission often occurs on the second or 

third day. 
Yellow fever : a marked remission on the second or third day. 
Dengue: a marked remission on the third or fourth day, 

which lasts two or three days, and is repeated about the 

ninth or tenth day. 






SUBNORMAL TEMPERATURE. 235 

The Infectious Fevers which are Associated with Jaun- 
dice: — 

Yellow fever. 

Relapsing fever. 

Acute yellow atrophy of the liver. 

Bilious remittent fever. 

Termination by Crisis. — The following infectious fevers are 
apt to end by crisis : — 

Typhus fever. Measles. 

Pneumonia. Relapsing fever. 

Influenza. Erysipelas. 

SUBNORMAL TEMPERATURE. 

Temperatures below 97.5° may be considered subnormal. 
They are observed in the following conditions : — 

1. During convalescence from certain febrile diseases; after 
pneumonia and typhoid fever the temperature may remain 
subnormal for several days. 

2. In collapse. This may result from shock ; from hemor- 
rhage ; from the action of some toxic agent ; from simple heart- 
failure in the course of disease ; or from the rupture of a viscus, 
as the bowel in typhoid, the lung in phthisis, or the stomach in 
perforating ulcer. 

3. In cholera. In this disease the temperature may be very 
low (90°-85°) for several days. 

4. In certain chronic diseases, especially diabetes, cancer, 
chronic cardiac, cerebral, and spinal diseases. 



236 ACUTE INFECTIOUS DISEASES. 



SIMPLE CONTINUED FEVER. 

(Febricula, Ephemeral Fever.) 

Definition. — An acute febrile disease, of short duration, 
and not excited by a special poison. 

Etiology. — It is generally met with in young and sensi- 
tive individuals. Exposure to the sun, prolonged physical or 
emotional excitement, and errors in diet seem to excite it. 

Symptoms. — The disease usually begins abruptly with 
chilliness, headache, malaise, and fever which soon attains a 
maximum of 102° or 103°. The face is flushed ; the pulse is 
full and rapid ; the urine is scanty and high colored ; the 
tongue is coated ; the appetite is lost ; and the bowels are con- 
stipated. There is no characteristic eruption, but herpes is 
frequently observed on the lips. 

The disease lasts from a few days to two weeks, and may 
end by crisis or lysis. 

Diagnosis. — Care must be taken to exclude local inflam- 
mations, such as gastritis, tonsillitis, and pneumonia. 

Typhoid Fever. — At first the diagnosis may be impossible, 
but the absence of diarrhoea, tympanites, abdominal tender- 
ness, splenic enlargement, and eruption will soon make the 
diagnosis apparent. 

Remittent Fever, — The history, locality, splenic enlargement, 
and hsematozoa in the blood will serve to distinguish this dis- 
ease from simple continued fever. 

Prognosis. — Favorable. 

Treatment. — Absolute rest in bed. A liquid diet. Re- 
peated small doses of calomel may be employed to relieve the 
constipation. 

The fever may be controlled by sponging with water and 
alcohol or by the use of some mild refrigerant mixture like the 
following : — 

Tinct. aconit. rad., gtt. iij ; 
Spt. aether, nitrosi, f§ ss ; 
Liquor, amnion, acetat., q. s. ad f^iij. — M. 
Sig. — A dessertspoonful every two hours to a child of four years. 



TYPHOID FEVER. 237 

TYPHOID FEVER. 

(Enteric Fever, Typhus Abdominalis.) 

Definition. — An acute infectious disease, excited by a 
special bacillus, characterized anatomically by definite lesions 
in Peyer's patches, mesenteric glands, and spleen ; and mani- 
fested clinically by fever, headache, stupor, abdominal disten- 
tion and tenderness, diarrhoea, enlargement of the spleen, and 
a rose-colored abdominal rash. 

Etiology. — Predisposing causes : Autumn season, early 
adult life, and a personal susceptibility. 

Exciting cause : The bacillus of Eberth. The intestinal 
discharges are the source of the contagion, and drinking-water 
contaminated by them becomes the chief medium of trans- 
mission. 

Pathology. — The characteristic lesions are found in the 
abdominal lymphatics, namely, in Peyer's patches, solitary 
glands, and mesenteric glands. The changes in Peyer's glands 
are best studied in the lower part of the ileum, which should 
be opened on the side of the mesenteric attachment. 

In the first few days the glands are swollen and hypersemic ; 
later there is a marked cell -proliferation, the bloodvessels are 
compressed, and the glands become pale and prominent (me- 
dullary infiltration). If the disease advances, necrosis sets in 
about the second week ; the glands become yellow and soft 
and discharge their contents, leaving behind irregular oval 
ulcers with swollen and undermined edges, and with smooth 
bases formed by the submucous coat, muscular coat, or perito- 
neum. In the fourth week cicatrization begins, and the gland 
is ultimately replaced by a smooth depressed scar. 

In addition to these glandular lesions, the mucous membrane 
of both large and small intestines shows catarrhal changes. 

In mild cases the stage of ulceration may not be reached, 
the proliferated cells being removed by fatty degeneration and 
absorption without rupture of the gland. The solitary and 
mesenteric glands pass through similar changes, but the latter 
rarely rupture. Other lesions are found which are not charac- 
teristic. The spleen is soft and swollen, and occasionally rup- 



238 ACUTE INFECTIOUS DISEASES. 

tures. The liver, kidneys, heart, and muscles reveal paren- 
chymatous degeneration. The respiratory tract is commonly 
the seat of catarrhal inflammation. 

Period of Incubation. — Two to three weeks. 

Fig. 17. 



Temperature curve in typhoid fever. 

Symptoms. Prodromal Symptoms. — Gradual weakness, 
headache, vague pains, nose-bleed, and often slight diarrhoea. 

The Attack. Fever. — The temperature rises gradually, reach- 
ing a maximum (104°— 105°) in from one to two weeks; it 
remains at this elevation for another period of from one to 
two weeks, when a gradual defervescence begins and occupies 
a third period lasting from one to two weeks. Throughout 
its course the fever is characterized by marked daily remis- 
sions, the evening temperature being from one to three degrees 
higher than the morning. 

In some cases, especially in the young, the temperature rises 
quite abruptly. Slight diurnal remissions indicate a protracted 
case. As defervescence advances, the temperature becomes 
more irregular ; the remissions are more decided, and not in- 
frequently the higher temperature is recorded in the morning. 
An abrupt fall of several degrees should suggest intestinal 
hemorrhage or perforation. 

Respiratory Symptoms. — Hurried respirations, slight cough, 
and bronchial rales. 

Circulatory System. — The pulse becomes rapid, weak, and 
dicrotic. The rapidity is often less than such temperatures 
generally produce. The heart-sounds become feeble. The 
first is especially weak and resembles the second. 



TYPHOID FEVER. 239 

The Face. — The expression is dull and heavy, the cheeks 
are somewhat flushed, the conjunctivae are clear, and the pupils 
dilated. 

The tongue is tremulous ; at first it is red at the tip and 
edges, and covered posteriorly with a whitish fur. In severe 
cases the tongue becomes dry, brown, and fissured, and sordes 
collect on the teeth. 

The Stomach. — Gastric symptoms are not common, but ob- 
stinate vomiting sometimes develops and becomes a serious 
complication. 

Intestinal Symptoms. — The belly is distended with gas. Ten- 
derness is frequently noted on palpation ; it may be general, or 
confined to the right iliac fossa. Gurgling may also be detected 
in the latter region, but it has little significance. Diarrhoea is 
generally present, though it is not a constant symptom. The 
discharges vary in number from three to six or more a day ; 
they are thin, offensive, and of a yellowish color (likened to 
pea-soup) ; on standing, a turbid liquid rises to the top and a 
granular sediment falls to the bottom. 

The Eruption. — This appears from the seventh to the ninth 
day, and is most abundant on the abdomen, though it is not 
infrequently observed on the chest and back. It is composed 
of small, slightly elevated, rose-colored spots which disappear 
on pressure. It comes out in successive crops over several days. 
It may be absent particularly in the old and very young. 
Rarely, in malignant cases, is the eruption petechial. 

Sudamina are also noted, and result from the free perspira- 
tion. 

Nervous Symptoms. — Headache, slight deafness, stupor, 
muttering delirium, twitching of the tendons (subsultus ten- 
dinum), picking at the bedclothes or imaginary objects (car- 
phologia), and coma vigil (the eyes are open, but the patient 
is unconscious). 

The urine is febrile and often slightly albuminous. Reten- 
tion is common. 

Convalescence is marked by anaemia, falling of the hair, de- 
squamation of the cuticle, and often mental enfeeblement. 

Varieties. Mild Typhoid. — There is moderate fever with 
marked remissions ; the diarrhoea is slight ; nervous symp- 



240 ACUTE INFECTIOUS DISEASES. 

tonis are often absent ; the rash is usually present, and often 
abundant. 

Abortive Typhoid. — There is an abrupt onset with severe 
symptoms, but convalescence follows in a few days. 

Walking Typhoid. — The symptoms are mild, and often dis- 
regarded by the patient, who refuses to go to bed ; but grave 
symptoms may develop suddenly, and death from perforation 
is not uncommon. 

Typhoid in Children. — The rash is often absent ; the fever 
rises abruptly ; cerebral symptoms are marked. 

Complications. — Any symptom aggravated constitutes a 
complication ; thus high fever, excessive diarrhoea, and tym- 
panites become complications. 

Hemorrhage. — This usually occurs during the third week, 
and is indicated by a sudden fall of temperature, followed by 
dark red or tarry stools. 

Peritonitis. — This may result from perforation, or from ex- 
tension by contiguity. The former is the most common, and 
is recognized by a sudden pain, a fall of temperture, disten- 
tion of the belly, and symptoms of peritonitis. 

Pneumonia and hypostatic congestion of the lungs are com- 
mon complications. 

Among less frequent complications or sequelae may be men- 
tioned : Nephritis, pyelitis, tuberculosis, temporary insanity, 
and phlegmasia dolens. 

Kelapse and Eecrudescence. — Relapses are quite com- 
mon ; they repeat the symptoms of the original attack, but 
they are generally milder and of shorter duration, and seldom 
prove fatal. 

Recrudescence. — This is a sudden temporary elevation of 
temperature occurring during convalescence, and is not asso- 
ciated with a return of the other symptoms. It is usually due 
to constipation, excitement, or irritating food. 

Diagnosis. — Acute miliary tuberculosis often closely resem- 
bles typhoid fever. In tuberculosis the temperature is gen- 
erally more irregular; the abdominal symptoms are less 
marked ; pulmonary symptoms, especially dyspnoea, are more 
marked j the rash is absent ; tubercles may be detected on the 






TYPHOID FEVER. 241 

retina ; and symptoms of basilar meningitis may be present, 
such as irregular pupils, ptosis, and strabismus. 

Ulcerative Endocarditis. — The diagnosis may be impossible, 
but the following features would suggest endocarditis : The 
history of a primary disease which might induce ulcerative 
endocarditis; irregular fever; intercurrent rigors; precordial 
pain and endocardial murmurs ; and the absence of a rose- 
colored rash and of marked abdominal symptoms. 

Enteritis. — The absence of high fever, of eruption, of splenic 
eulargement, of epistaxis, of bronchial catarrh will serve to 
distinguish enteritis from typhoid fever. 

Meningitis. — The abrupt onset, the early development of 
cerebral symptoms, the irregular fever, and the absence of a 
rash and of abdominal symptoms will indicate meningitis. 

Prognosis. — The prognosis should always be guarded. No 
case is too mild to prove fatal, and no case is too severe to 
recover. The mortality varies in different epidemics. In 
private practice the average is probably between five and ten 
per cent., and in hospital practice it is somewhat more. 

Continued high fever with slight diurnal remissions, exces- 
sive diarrhoea, severe cerebral symptoms, and repeated hemor- 
rhages are unfavorable features. 

Treatment. — Absolute rest in bed and the enforced use 
of the bed-pan. The stools should be rendered innocuous. 
This may be done by dissolving a pound of chloride of lime 
in four gallons of water, and adding a quart of the solution 
to each discharge, and allowing it to remain in the vessel at 
least an hour before disposing of it. Soiled bedclothes 
should be thoroughly boiled. 

The diet must be liquid, and preferably milk. From two 
to four pints should be given in the twenty-four hours, and 
should be so divided that the patient shall receive a small 
amount every two hours, day and night. When it causes 
eructations or flatulence, or is discharged undigested, it must 
be mixed with lime-water, or be predigested. Koumiss is 
often acceptable. Meat-broths may be given to vary the 
monotony of a milk diet. Cool water or ice will be required 
to allay thirst, and even if the latter is absent, it is well to 
give one or the other at regular intervals. When the first 
16 



242 ACUTE INFECTIOUS DISEASES. 

sound of the heart weakens and the pulse becomes soft, stimu- 
lants should be administered. It is desirable to give the 
alcohol with the milk so as to stimulate the stomach to digest 
the latter, and at the same time to diminish the number of 
administrations of food and medicine. From four to eight 
ounces of brandy or whiskey may be required in the twenty- 
four hours, the amount being determined by the general effect. 
When additional stimulation is required strychnine is a valu- 
able adjunct. 

When the tongue becomes dry and brown, the belly much 
distended, and low nervous symptoms develop, turpentine 
will be found an invaluable stimulant. Five to ten minims 
may be given in capsule or emulsion every two or four hours. 

Antiseptic remedies have been strongly advocated, but their 
efficiency has not been clearly demonstrated. Thymol, naphthol, 
carbolic acid, iodine, and calomel are the antiseptics which 
have been recommended. 

Fever. — This is best controlled by the external application 
of cold. When the temperature tends to remain above 102°, 
sponging with cool water, or with equal parts of alcohol and 
water, should be instituted. High temperature should be 
treated, when feasible, by the cold pack or the cold bath. 
Great prostration, hemorrhage, and peritonitis are contra- 
indications to this method of treatment. When circumstances 
prevent the use of the cold bath, internal antipyretics may be 
employed. The best are quinine (gr. xx-xxx), antifebrin 
(gr. v-x), and phenacetin (gr. v-vj). 

Diarrhoea. — When diarrhoea exceeds more than three or 
four stools a day, it is well to check it by an opium sup- 
pository, or by bismuth or nitrate of silver by the mouth . 

I£ Pulv. opii, gr. iij ; 

01. theobrom., q. s.— M. 
Ft. in suppos. No. vi. 
Sig. — One, two or three times daily. 

Or— 

T$l Morph. sulph., gr. j ; 

Creasot., gtt. vj ; 

Bismuth, subnit., ^iij. — M. 
Ft. in chart. ~No. xii. 
Sig. — One every two or three hours. 



TYPHUS FEVER. 243 

Or— 

J$l Argenti nit., gr. v ; 
Ext. opii, gr. iv. — M. 
Ft. in pil. No. xx. 
Sig. — One every three hours. 

Constipation. — This may be relieved by an enema of soap 
and water, or by broken doses of calomel. 

Tympanites. — Turpentine stupes. Turpentine or thymol in- 
ternally. In grave cases, rectal intubation. 

Hemorrhage. — An ice-bag to the right iliac fossa. Morphia 
(gr. J) with ergotine (gr. v-x) hypodermically. Turpentine 
or gallic acid may be administered by the mouth. 

Perforative Peritonitis. — This is almost invariably fatal. 
Opium should be administered freely. Laparotomy is rarely 
warrantable 

Heart-failure. — When alcohol is being pushed and the 
symptoms of heart-weakness still persist, such remedies as 
aromatic spirits of ammonia, ether, strychnine, digitalis, or 
cocaine may prove useful. 

Grave Nervous Symptoms. — Delirium, subsultus, insomnia, 
etc. may be due to fever or lack of stimulation ; cold bathing 
is indicated in the former, and the free use of alcohol in the 
latter. Nerve sedatives, like the bromide of potassium, musk, 
hyoscine, and camphor are sometimes required. 

TYPHUS FEVER. 

(Ship Fever, Jail Fever.) 

Definition. — An acute contagious disease unassociated 
with any characteristic lesions of the solids, and manifested by 
great prostration, a petechial rash, marked nervous symptoms, 
and high fever which defervesces by crisis in from ten to 
fourteen days. 

Etiology. — It is excited by an unknown poison which is 
capable of being carried in clothes (fomites). It is rare in 
America, but not uncommon in England and Ireland. Bad 
food, impure water, overcrowding, and foul air are predis- 
posing factors. 



244 



ACUTE INFECTIOUS DISEASES. 



Pathology. — There are no characteristic lesions of the 
solids. As in other fevers, the liver and spleen are swollen, 
and the tissues reveal fatty and parenchymatous degeneration. 
The blood shows a peculiar change : it is dark, fluid, and 
stains the lining of the heart and great bloodvessels bright red. 

Period of Incubation. — A few hours to two weeks. 



Fig. 18. 




Temperature chart of typhus. 



Symptoms. — Typhus fever begins abruptly with pain in 
the head, back, and limbs ; extreme prostration ; and fever 
which reaches its maximum (104°-105°) in two or three days. 
The temperature remains high for about ten days, when it 
falls by crisis. 

The pulse is rapid, weak, and often dicrotic. The tongue 
is tremulous, and usually covered with a whitish fur ; but in 
bad cases it becomes black and rolled up like a ball in the back 
of the mouth. 

The face is dusky; the conjunctivae are injected ; and the 
pupils are contracted. 

Nervous Symptoms. — These are prominent, and consist of 
headache, stupor, delirium, subsultus tendinum, carphologia, 
and coma vigil. 

The Eruption. — About the fourth or fifth day rose-colored 
spots appear over the body ; these rapidly become hemorrhagic, 
or petechial, and fail to disappear on pressure. . There is a 
distinct relation between the amount of eruption and the 
severity of the attack. In addition to this " mulberry rash," 
there is often a diffuse, dark-red subcuticular mottling. 






RELAPSING FEVER. 245 

Gastro-intestinal Symptoms. — The stomach is retentive, and 
the bowels are constipated. 

Urine. — The urine is scanty, high-colored, and often albu- 
minous. 

Complications. — Hyperpyrexia, catarrhal pneumonia, 
hypostatic congestion of the lungs,- nephritis, and parotid 
abscess. 

Diagnosis. Cerebrospinal Meningitis. — In this affection 
the pain in the back is greater. The fever is very irregular ; 
there is greater tendency to opisthotonos and facial palsies ; and 
the eruption, though it may resemble that of typhus, is incon- 
stant and without a special time for appearing. 

Typhoid Fever. — The resemblance is in the nervous phe- 
nomena only. In typhoid the fever rises and falls very 
gradually ; the eruption appears later, remains rose-red, and 
does not become petechial ; the face is not dusky, the eyes are 
not injected ; and there are marked abdominal symptoms. 

Prognosis. — The mortality is much greater than in typhoid 
fever. Advanced years and alcoholism render the prognosis 
decidedly unfavorable. 

Treatment. — Isolation ; absolute rest ; liquid diet. There 
is no specific treatment. Alcohol is nearly always required. 
Quinine and mineral acids are useful tonics. 

Pyrexia, nervous phenomena, and heart-failure should be 
treated as in typhoid fever. 

RELAPSING FEVER. 

(Spirillum Fever, Famine Fever.) 

Definition. — An acute contagious disease excited by the 
spirochete of Obermaier, and characterized by paroxysms of 
high fever which last five or six days and are followed by in- 
termissions of a similar duration. 

Etiology. — The exciting cause is the spirochete of Ober- 
maier, a spiral-shaped microbe three or four times as long 
as the diameter of a red blood-corpuscle. Bad water, poor 
food, overcrowding, and foul air predispose to epidemics. 
The disease is highly contagious. 



246 ACUTE INFECTIOUS DISEASES. 

Pathology. — There are no characteristic lesions. The 
liver and spleen are much enlarged, and the latter is frequently 
the seat of infarctions. There is usually catarrhal inflamma- 
tion of the stomach and bile-ducts. The spirochete is found in 
the blood duriDg life, but only during the paroxysms ; after 
death it is found in all the organs. 

Period of Incubation. — Five to eight days. 

Fig. 19. 




Temperature curve in relapsing fever. 

Symptoms. — The disease begins abruptly with a chill fol- 
lowed by fever, which reaches its maximum (10o°-106°) in 
twenty-four hours, and remains high for from five to seven 
days, when it falls by crisis. After an intermission of five or 
six days it again rises rapidly and remains high for a similar 
period. Convalescence usually begins at the end of the second 
paroxysm, but it may not begin until after the third or fourth. 
Other noteworthy symptoms are intense pains in the head, 
back, and limbs ; the spirochete in the blood ; and frequently 
jaundice. 

Complications. — Hyperpyrexia, nephritis, pneumonia, and 
ophthalmia. 

Diagnosis. Rheumatic Fever. — The history, irregular fever, 
acid sweats, and the absence of spirilli and of jaundice will 
serve to distinguish rheumatism from relapsing fever. 

Remittent Fever. — In this disease the fever remits, but does 
not intermit ; the paroxysms are more frequent ; and instead 
of spirilli, haematozoa are found in the blood. 



CEKEBBO-SPLNAL FEVEK. 247 

Yellow Fever. — The single remission on the second or third 
day, the bloody vomit, and the absence of spirilli and of splenic 
enlargement will indicate yellow fever. 

Prognosis. — Favorable in uncomplicated cases. 

Treatment. — Isolation ; rest ; liquid diet. As a general 
tonic, quinine is useful. For the pains, anti pyrin, phenacetin, 
or morphia may be given internally, and rubefacients used 
locally. For the irritable stomach hot fomentations may be 
applied to the epigastrium, and small doses of calomel and 
soda administered internally. 

CEREBROSPINAL FEVER. 

(Epidemic Cerebro-Spinal Meningitis, Spotted Fever.) 

Definition. — A specific infectious disease characterized 
anatomically by inflammation of the cerebro-spinal meninges, 
and clinically by intense pain in the head, back, and limbs, 
convulsions, irregular fever, and frequently by a petechial 
eruption. 

Etiology. — The disease may be sporadic or epidemic. 
Overcrowding, poor food, foul air, and bad drinking- water 
seem to predispose to epidemics. Outbreaks are most common 
in the winter and spring. The young are more susceptible 
than the old. The disease is not contagious ; the method of 
transmission is still unknown. 

The Exciting Cause. — This is unquestionably a micro-organ- 
ism. Certain diplococci have been repeatedly found in the 
exudations, but they have not been proven to be the exciting 
factors. 

Pathology. — In most cases the membranes of the brain 
and cord are deeply congested and opaque. Lymph and pus 
are found both at the base and on the convexity of" the brain, 
especially in the fissures and along the bloodvessels. The 
spinal meninges present similar changes, the posterior surface 
of the cord being particularly involved. 

The liver and spleen are engorged and the muscles reveal 
granular degeneration. In rapidly fatal cases the lesions are 
very slight. 



248 ACUTE INFECTIOUS DISEASES. 

Symptoms. Common Form. — The disease geDerally begins 
abruptly with a chill, followed by vomiting and excruciating 
pain in the head, back, and limbs. The muscles of the neck 
and back become rigid and contracted, so that the head is bent 
backward and the back is straightened ; in severe cases the 
body may be arched in a state of opisthotonos. The mind is 
soon affected ; delirium is rarely absent, aud in severe cases it 
is followed by stupor and coma. 

Involvement of the Cranial Nerves. — Pressure of the exudate 
upon the cranial nerves may produce the following symptoms : 
Nystagmus (tremor of the eyeball); strabismus; ptosis; irregu- 
lar, sluggish pupils ; and partial deafness or blindness. 

Involvement of the Spinal Nerves. — There is extreme cutaneous 
hyperesthesia, so that the slightest touch excites pain. The 
muscles of the extremities are stiff and may twitch, but are 
rarely palsied. The patellar reflex is usually diminished. 
The joints are occasionally red, swollen, and painful. 

Febrile Symptoms. — The temperature is irregular in its 
course and indefinite in its duration ; ordinarily it ranges be- 
tween 101° and 103°, but in some cases it is almost normal, 
and in others it is very high. The pulse is rapid and full ; 
the bowels are constipated ; and the urine may contain albumin 
and sugar. Polyuria is an occasional symptom. 

The Eruption. — The eruption is neither constant nor pecu- 
liar. In many cases a blotchy purpuric rash appears over the 
entire body. Herpes facialis is also frequently observed. In 
other cases urticaria, or a roseolar or erythematous rash ap- 
pears. 

The duration is from a few hours to several weeks. " In 
favorable cases, convalescence is very protracted. 

Fulminant Form.— There is an abrupt onset with a chill, 
followed by vomiting, headache, moderate fever, convulsions, 
a petechial or purpuric rash, and death in a few hours from 
collapse. 

Abortive Form. — The disease begins abruptly with grave 
symptoms, but terminates in a few days in recovery. 
* Intermittent Form. — The fever is* characterized by inter- 
missions or marked remissions which occur daily or every 
other day. 



CEREBROSPINAL FEVER. 249 

Diagnosis. Typhoid Fever. — The gradual onset, the regu- 
lar fever, the diarrhoea and tympanites, and the absence of 
rigidity, of intense pain in the back and limbs, of facial palsies 
and of herpes, will separate typhoid from cerebro-spinal fever. 

Typhus Fever. — The regular fever, the absence of intense 
pain in the back and limbs, of facial palsies, and of muscular 
rigidity, will distinguish typhus from cerebro-spinal fever. 

Acute articular rheumatism may resemble cerebro-spinal 
meningitis, but the early involvement of the joints, the acid 
sweats, and the absence of rigidity, of eruption, and of facial 
palsies, will distinguish it from cerebro-spinal meningitis. 

Tuberculous Meningitis. — In this disease the onset is less 
abrupt ; there is less tendency to opisthotonos ; herpes is rare ; 
and petechia? are always absent. Tuberculous meningitis in 
the adult is always secondary to tuberculosis elsewhere. 

Prognosis. — The mortality varies in different epidemics 
from 20 to 80 per cent. The prognosis should always be 
guarded ; the mildest cases may prove fatal. Severe cerebral 
symptoms usually indicate a fatal termination. 

Complications and Sequels. — Defective vision from 
inflammation of the cornea or retina, or from atrophy of the 
optic nerve ; defective hearing from inflammation of the 
auditory nerve, or from suppurative inflammation of the 
internal or middle ear ; pneumonia ; arthritis ; aphasia ; periph- 
eral palsies ; chronic hydrocephalus ; and persistent head- 
ache from chronic meningitis. 

Treatment. — A liquid or semi-liquid diet. Ice-bags may 
be applied to the head and along the spinal column. Pain 
and restlessness should be relieved by morphia, bromides, or 
chloral. Morphia is especially efficacious, and may be injected 
along the course of the most painful nerve-trunks. Dry or 
wet cups over the spine are sometimes useful. Iodide of 
potassium (gr. v-x thrice daily) may be administered internally. 
Dr. Pepper recommends quinine (gr. v thrice daily) with the 
fluid extract of ergot (3j every three or four hours). When 
the pulse weakens, stimulants should be given freely. High 
fever may be controlled by sponging with cold water, by the 
cold pack, or by the internal use of phenacetin or antipyrin. 



250 ACUTE INFECTIOUS DISEASES. 

During convalescence, iodide of potassium as an absorbent, 
tonics, and blisters to the spine are indicated. 

MALARIAL FEVER. 

(Chills and Fever, Fever and Ague, Swamp Fever.) 

Definition. — A specific non-contagious disease, invariably 
associated with, and probably excited by, the hcematozoa of 
Laveran, and characterized by splenic enlargement, by fever 
with periodic intermissions or remissions, and by a tendency 
to extreme anaemia. 

Etiology. — A warm climate and the summer season, a 
moist atmosphere ; low, badly-drained soil ; and decaying 
vegetable matter are the conditions which favor the develop- 
ment of the malarial poison. 

Special Predisposing Causes. — Residents in the lowlands are 
more liable to be infected than those who dwell on the hills ; 
one attack seems to predispose to others ; visitors to malarial 
districts are more susceptible than permanent residents ; in 
the night and in the early morning the air is thoroughly im- 
pregnated with the miasm, and exposure at such times is very 
apt to be followed by infection. 

Exciting Cause. — The hosmatozoon first described by Laveran 
is probably the exciting cause of malaria. 

Manifestations. — Malarial intoxication may manifest 
itself as (1) intermittent fever; (2) remittent fever; (3) perni- 
cious malarial fever ; and (4) chronic malarial cachexia. 

Pathology. — The bodies found in the blood of those 
suffering with malarial fever belong to the protozoans. Vari- 
ous forms are noted, some of which are distinct species, while 
others are merely phases of existence in the life of the same 
organism. These different species and phases have to a limited 
extent been associated with the different clinical manifestations 
of the disease. 

The organisms are most commonly found within the red 
corpuscles, and are most abundant during the paroxysms. 
The following are 'the principal forms : (1) A pigmented amoe- 
boid form ; (2) a non-pigmented amoeboid form ; (3) a crescentic 
form ; (4) a flagellate form. Intermittent fever is generally 



MALARIAL FEVER. 251 

associated with the amoeboid forms. The crescents are found 
particularly in remittent fever and in chronic malarial cachexia. 
The flagellate form is rarely found in man. When present in 
the blood, they destroy the red corpuscles, liberate the pig- 
ment, and ultimately lead to extreme anasmia. 

Fig. 20. 




Various forms of htematozoa. 



In advanced malaria the blood shows a diminished number 
of red blood-corpuscles and an abundance of free pigment 
(melansemia). The spleen is greatly swollen and deeply pig- 
mented (ague-cake) ; the liver is moderately enlarged and 
pigmented. All the organs, including the brain and spinal 
cord, are discolored by the liberated pigment. 

Intermittent Fever. 

Definition. — A form of malarial fever, characterized by 
febrile paroxysms which are attended with a cold, a hot, and a 
sweating stage. 

Symptoms. Cold Stage. — Malaise ; headache ; great chilli- 
ness. The features are pinched ; the lips are blue ; the surface 
of the body is cold and covered with cutis anserina (goose- 
flesh), although the rectal temperature is high (104°-105°). 
Vomiting may occur. The chill lasts from a few minutes to 
an hour or two. 

Hot Stage. — The surface temperature gradually rises ; the 
skin becomes hot ; the face flushed ; the eyes injected ; and 
the pulse full and rapid. The temperature in the axilla may 
reach 106° or 107°. The patient complains of severe pain in 
the head, back, and limbs, and of intense thirst. The urine 
is scanty and dark-colored. This stage usually lasts from one 
to five hours. 



252 ACUTE INFECTIOUS DISEASES. 

Sweating Stage. — The fever gradually subsides ; the pain 
grows less ; free perspiration follows ; and the patient falls to 
sleep, from which he awakes feeling fairly well. 

Percussion reveals enlargement of the spleen ; and an ex- 
amination of the blood during the paroxysm shows the hsema- 
tozoa undergoing segmentation. 

Varieties. — When the paroxysms occur every day, the 
disease is termed quotidian intermittent; every other day, 
tertian intermittent ; every fourth day, quartan intermittent. 
When two paroxysms occur in a single day the disease is 
termed double quotidian intermittent. 

Diagnosis. — The presence of hsematozoa in the blood will 
serve to distinguish malaria from all other intermittent types 
of fever. 

Prognosis. — Always favorable. Even when no treatment 
is instituted, the paroxysms gradually subside. Chronic ma- 
larial cachexia sometimes results from the acute disease. 

Remittent Fever. 

(Bilious Remittent Fever, Jungle Fever.) 

Definition. — A form of malaria i n which the temperature 
distinctly remits, but does not intermit. 

Etiology. — This form occurs especially in the marshy dis- 
tricts of hot climates. Remissions, instead of intermissions, 
indicate a greater virulence of the poison, or a greater suscepti- 
bility on the part of the patient. 

Symptoms. — Malaise with moderate chilliness, followed by 
a continuous fever which daily remits. The maximum tem- 
perature ranges from 104° to 106°, and while this lasts the 
skin is hot, the face is flushed, the eyes are injected, the 
pulse is full and rapid, the urine is scanty, and the patient 
complains of pain in the head and limbs. Delirium is some- 
times noted ; vomiting often occurs ; and jaundice may develop 
from destruction of the red blood-corpuscles and liberation of 
their pigment. The spleen is enlarged, and an examination of 
the blood reveals hsematozoa. 

In some cases the symptoms resemble typhoid fever, and to 






MALARIAL FEVER. 253 

these the term typho-malarial fever has been applied. In 
severe cases the symptoms resemble pernicious malarial fever. 

Diagnosis. Typhoid Fever. — The absence of diarrhoea, of 
tympanites, of eruption, and of a gradual rise in temperature, 
and the presence of haematozoa and of marked remissions will 
serve to separate remittent fever from typhoid. 

Yellow Fever. — The splenic enlargement, the hsematozoa, 
the multiple remissions, and the absence of bloody vomit will 
separate remittent from yellow fever. 

Prognosis. — Favorable ; the average duration is from one 
to two weeks. 

Pernicious Malarial Fever. 

(Congestive Chills, Malignant Malaria.) 

Definition. — A malignant form of malaria, occurring es- 
pecially in the tropics, and characterized by choleraic symp- 
toms, by coma, or by a tendency to bleed from the various 
organs. 

Varieties. — According to its expression, the following 
varieties have been made : (1) Algid ; (2) comatose ; (3) hem- 
orrhagic. 

Symptoms. Algid. — The symptoms resemble the cold 
stage of cholera. The surface is cold ; the temperature may 
be subnormal ; there is great prostration ; the features are 
pinched ; the pulse is feeble. Vomiting and purging may 
follow ; death often results in collapse. 

Comatose. — There is delirium, rapidly followed by stupor 
and coma ; the latter may or may not be associated with con- 
vulsions. The skin is hot ; the face is flushed ; the eyes in- 
jected ; and the temperature high. The symptoms gradually 
disappear, but unless the patient is speedily cinchonized they 
return and commonly prove fatal. 

Hemorrhagic. — In this form hemorrhages occur from the 
mucous membranes, especially from the kidneys, stomach, and 
bowels, and the patient is frequently jaundiced. 

Diagnosis. — The algid form may resemble cholera, but the 
history, the absence of an epidemic, and the presence of the 
hsematozoa in the blood will render the diagnosis apparent. 



254 ACUTE INFECTIOUS DISEASES. 

Yellow Fever. — The hemorrhagic form may resemble yellow 
fever, but the splenic enlargement, the late appearance of jaun- 
dice, the presence of hsematozoa in the blood, and the absence 
of an epidemic will serve to distinguish the two diseases. 

Prognosis. — Extremely guarded ; the first paroxysm rarely 
kills, but unless the patient is thoroughly cinchonized a second 
one may prove fatal. 

Chronic Malarial Cachexia. 

Definition. — A chronic manifestation of malaria, charac- 
terized by anaemia, by a sallow appearance of the skin, and by 
splenic enlargement. 

Etiology. — It may result from repeated attacks of the 
acute disease, or it may develop as a primary condition from 
slow infection. 

Symptoms. — The patient is thin and pale; the complexion 
is of a dirty yellow or muddy hue ; fever is often absent ; if 
present, it is slight and irregular ; the spleen is considerably 
enlarged. There is great weakness from the attending anaemia. 
Headache and neuralgia are common symptoms. Hematuria 
is sometimes observed. 

Diagnosis. Leuccemia. — The history, the absence of leuco- 
cytosis and of lymphatic enlargements, and the presence of 
haeuiatozoa in the blood will indicate malaria. 

Prognosis. — Guarded. When the spleen is very large and 
there is extreme anaemia, recovery rarely follows. 

Other Manifestations of Malaria. 

One of the following conditions may be the chief manifes- 
tation of malarial intoxication : Neuralgia, headache, hema- 
turia, purpura, orchitis, or paraplegia. 

Malarial infection seems to predispose to certain cases of 
dysenterv, of pneumonia, and of amyloid degeneration of the 
viscera. 

Treatment of Malarial Diseases. Prophylaxis. — 
Patients living in malarial districts should avoid the night 
and early morning air, and should take quinine (gr. iij-v a 
day) during the season in which the disease is prevalent. 



MALARIAL FEVER. 255 

Cold Stage of Intermittent. — Cover the patient with blankets, 
and apply hot cans or hot bottles to the feet. When the chill is 
severe and prolonged, morphia is very useful ; it may be given 
hypodermically. Hoffmann's anodyne may be employed 
as a substitute. Inhalations of nitrite of amyl are followed 
by dilatation of the superficial bloodvessels, and in this way 
serve to shorten the chill. 

Hot Stage of Intermittent, — Sponge the body with cool 
water, and if the symptoms are severe phenacetin may be 
given to lower the temperature and to lessen the pain. 

The Interval, — It is well to begin the treatment by the 
administration of a laxative, and calomel may be selected. 
This should be followed by quinine (gr. xv-xx) in divided 
doses, so that the last dose is taken two hours before the time 
of the expected paroxysm. In children, quinine may be given 
in lozenges made with chocolate and sugar. In adults, it is 
best administered in fresh pills or in capsules. These doses 
of quinine should be continued until the paroxysms disappear, 
when the amount may be gradually diminished. The treat- 
ment should be continued for several weeks. During conva- 
lescence it is advisable to give arsenic in the form of Fowler's 
solution with the quinine. The following pill is also useful 
in the convalescence of malaria : — 

J$l Acid, arseniosi, gr. ss ; 

Quinin. sulph., ^j ; 

Ferri pyrophos., gr. xxx ; 

Pulv. capsici, gr. xv. — M. 
Ft. in pil. No. xxx. 
Sig. — One thrice daily. 

Remittent Fever. — Absolute rest. A light diet. Quinine 
(gr. xx-xxx) should be given in divided doses in the course 
of a day. A laxative dose of calomel is a valuable adjunct to 
the antiperiodic treatment. When the stomach is irritable 
calomel and soda may be given by the mouth, and the quinine 
by the rectum or hypodermically. In some cases Warburg's 
tincture is useful ; half an ounce undiluted may be given, and 
repeated in two or three hours. After its administration the 
patient should be thoroughly covered with blankets so as to 
favor free diaphoresis. 



256 ACUTE INFECTIOUS DISEASES. 

Pernicious Malarial Fever. — From fifty to a hundred grains 
of quinine must be given before the second paroxysm occurs. 
It is advisable to begin at once without waiting for the inter- 
mission ; and twenty to thirty grains may be given hypoder- 
mically every two or three hours. 

fy. Q.uininse sulph. , gr. xl ; 

Sat. sol. acid, tartar., Tflxlviij ; 
Aquae destil., q. s. ad f^ij.— M. 
Sig. — Vf\ xxx == gr. x. 

When the pulse weakens, stimulants, like whiskey, ammonia, 
and strychnia, should be employed. High temperature should 
be controlled by the external application of cold. In the 
algid form, heat should be applied externally, and opium 
given by the mouth or hypodermically. In the hemor- 
rhagic form, opium is also useful, and it may be associated 
with haemostatics like turpentine, erigeron, or hamamelis. 

Chronic Malarial Cachexia. — Iron, quinine, and arsenic are 
the remedies indicated. 



SCARLET FEVEK. 

(Scarlatina.) 

Definition. — An acute contagious disease, characterized 
by high fever, a rapid pulse, a punctiform scarlet rash, sore 
throat, and an unusual tendency to nephritis. 

Etiology. — The specific poison of scarlet fever has not been 
isolated. The contagium is usually carried through clothes or 
other fomites, or in food Like milk. The disease can be 
transmitted by direct inoculation. The poison is tenacious 
and of extreme vitality ; infected clothes, unused for years, 
have led to outbreaks. The young are especially predisposed, 
but not equally so. Puerperal women and persons suffering 
from wounds are unusually susceptible. One attack does not 
give absolute immunity, but second attacks are uncommon. 

Pathology. — The throat is inflamed and sometimes ulcer- 
ated ; the liver and spleen are engorged ; the muscles reveal 
granular degeneration. Klein has observed hypersemia and 
cell-proliferation, not only in the throat and kidneys, but 



SCARLET FEVER. 257 

throughout the intestinal canal. The kidneys frequently show 
the lesions of hemorrhagic nephritis, the glomeruli being espe- 
cially involved. The rash is rarely detected after death. 

Varieties. — (1) Simple ; (2) anginoid ; (3) malignant. 

Period of Incubation. — A few hours to a week. 

Symptoms. — The disease generally begins suddenly, occa- 
sionally with a chill, but more commonly with vomiting or 
convulsions. 

Throat Symptoms. — Pain and difficult)^ in swallowing ; ful- 
ness and tenderness beneath the jaw ; enlargement of the 
lymphatic glands. The tongue is at first heavily coated and 
red at the tip and edges ; in a few days the coating almost 
entirely disappears, and the papillae become bright red and 
swollen. This appearance has given rise to the term " straw- 
berry tongue/' The pillars, tonsils, uvula, and pharyngeal 
vault are deeply injected and may reveal a punctiform efflo- 
rescence before the rash develops on the skin. In severe cases 
the tonsils may be the seat of follicular inflammation, or may 
be covered with false membrane. 

Eruption. — A scarlet-red punctiform rash appears at the end 
of the first, or at the beginning of the second day, on the neck 
and chest, and rapidly spreads over the entire body. It dis- 
appears on pressure, a white line remaining for a second or two 
when the finger-nail is drawn through it. It may be uniform 
or it may occur in discrete patches surrounded by healthy skin. 
In five or six days the red color gradually fades and scaly 
desquamation soon follows. 

In some cases the rash is pale and scarcely visible, in others 
it is slightly papular or vesicular (scarlatina miliaris) ; in ma- 
lignant cases it may be petechial. 

Febrile Symptoms. — The fever rises abruptly, reaching its 
maximum (104°-105°) in twenty-four or forty-eight hours, 
remains nearly uniform for three or four days, and then falls 
by lysis. The duration of the febrile period is from seven to 
nine days. The pulse is very rapid, — out of proportion to the 
fever ; the respirations are hurried ; the appetite is lost ; the 
bowels are constipated ; and the urine is scanty, high-colored, 
and often contains albumin. 
17 



258 ACUTE INFECTIOUS DISEASES. 

Nervous Symptoms. — Restlessness, headache, insomnia, de- 
lirium, and convulsions may occur in the course of the disease. 
Convulsions developing late in the disease are very significant 
of uraemia. 

Anginoid Scarlet Fever. — This form is characterized by 
severe throat symptoms. The tonsils are much swollen and 
are often covered with false membrane. The fever is high 
and the prostration is profound. Ulceration of the throat fre- 
quently occurs. Death may result from exhaustion, aspiration- 
pneumonia, or from hemorrhage due to ulceration of the 
carotid artery. 

Malignant Scarlet Fever. — The onset is abrupt, with a chill, 
vomiting, or convulsion ; the fever is very high (106°-107°) ; 
the pulse is rapid and feeble ; delirium sets in, and is followed 
by coma. Death may result before the appearance of the 
rash, in twenty-four or forty-eight hours. 

Complications. Nephritis. — This usually develops during 
convalescence, and as it may be unassociated with subjective 
symptoms the urine should be examined daily in order to de- 
tect its presence ; in other cases its advent is recognized by the 
suppression of urine, by uraemia, or by dropsy. Nephritis 
may be the immediate cause of death, but more commonly it 
ends in recovery ; it sometimes leads to chronic renal disease. 

Among other complications may be mentioned hyperpyrexia, 
endocarditis, pericarditis, pneumonia, suppuration of the lym- 
phatic glands, ophthalmia, inflammation of the middle ear, 
chorea, and a peculiar inflammation of the joints resembling 
rheumatism. 

Diagnosis. — Acute Tonsillitis may resemble scarlet fever, 
especially when the former is associated with an erythematous 
rash ; but in tonsillitis there is no history of contagion, the 
pulse is proportionate to the fever; the rash, if present, is not 
pnnctiform; the tongue has not the strawberry appearance; and 
there is no tendency to nephritis. 

Diphtheria. — The onset is less abrupt ; there is more pros- 
tration ; false membrane is always present ; a cutaneous rash 
is usually absent ; and the tongue does not present a straw- 
berry appearance. 

Measles. — The sore throat is less marked ; catarrhal symp- 
toms are present ; the rash appears later, is papular, and forms 






SCARLET FEVER. 259 

in crescentic-shaped patches ; the fever shows a decided remis- 
sion on the second or third day ; and the pulse is proportionate 
to the fever. 

Rothdn. — This may be difficult to distinguish from scarla- 
tina, but the fever is not so high, nor the pulse so rapid ; the 
post-cervical glands are more swollen ; there is no tendency 
to nephritis ; and if desquamation occurs it is branny. 

Accidental Rashes. — Certain drugs like belladonna, quinine, 
and copaiba, and certain foods, like crabs and oysters, may 
produce a rash like that of scarlet fever, but it is not puncti- 
form, and is not associated with high fever, sore throat, and 
rapid pulse. 

Prognosis. — Always guarded. The mortality varies in 
different epidemics from 5 to 40 per cent. 

Treatment. — Isolation. Absolute rest. Liquid diet. 
The surface of the body should be anointed two or three times 
daily with cold cream, cocoa-butter, or carbolized vaseline. 
The patient should be encouraged to drink water or lemonade 
freely. Gastric irritability may call for small doses of calo- 
mel, bismuth, or nitrate of silver. When the stomach is 
retentive, the tincture of the chloride of iron may be given 
with small doses of dilute hydrochloric acid, thus : — 

]£. Tinct. ferri chlor., f .^ij ; 
Acid, hydrocblor.dil., f^j ; 
Syr. limonis, f 3j ; 
Aquae, q. s. ad f^iij. — M. 
Sig. — Teaspoonful in water every two or three hours. 

The fauces and pharynx should be kept clean by antiseptic 
washes or sprays, such as DobelPs solution, dilute peroxide of 
hydrogen, or dilute listerine. 

Cerebral symptoms may be controlled by bromide of potas- 
sium, chloral, by an ice-bag to the head, or, when due to 
fever, by the cold bath. 

High fever is best treated by sponging, by the cold pack, 
or by the graduated cold bath. 

The urine should be examined daily for evidence of ne- 
phritis, and, if the latter arises, the diet should be cut down 
to skimmed milk or buttermilk ; dry cups may be applied to 
the loins ; the bowels kept active by Epsom or Rochelle salt ; 
and diaphoresis encouraged by small doses of jaborandi. 



260 ACUTE INFECTIOUS DISEASES. 

Cardiac weakness will call for stimulants like alcohol, am- 
monia, strychnia, and digitalis. 

Convalescence should be guarded and protracted. 

3IEASLES. 

(Rubeola, Morbilli.) 

Definition. — An acute contagious disease, characterized 
by catarrh of the respiratory tract, moderate fever, and a red 
papular eruption, which appears on the fourth day and termi- 
nates in two or three days by branny desquamation. 

Etiology. — Measles is highly contagious, and the poison 
may be transmitted through clothes and other fomites. The 
contagium is apparently associated with the nasal and bron- 
chial secretion, but it has not been isolated. It is most 
commonly observed in children, but unprotected adults are 
very liable to be attacked. It is essentially an epidemic dis- 
ease, but now and then sporadic cases occur. One attack is 
fairly protective, but does not give absolute immunity. 

Pathology. — The lesions consist in catarrh of the entire 
respiratory tract. Gastro-intestinal catarrh is not uncommon. 
In fatal cases such complications as capillary bronchitis, 
catarrhal pneumonia, and pulmonary collapse are frequently 
observed. 

Period of Incubation. — About two weeks. 

Symptoms. Prodromes. — Chilliness, coryza, watering of the 
eyes, photophobia, cough, and drowsiness. 

The Fever. — The temperature rises rapidly to 102° or 103°, 
but on the second day there is a decided remission, which 
continues until the fourth day, when the eruption appears ; at 
this time it again rapidly runs up to, or beyond, its original 
height, where it remains for two or three days and then falls 
by crisis. 

The Catarrh. — Redness of the conjunctivae, lachrymation, 
sneezing, hoarseness, cough, and expectoration. There may 
be vomiting or diarrhoea. 

The Eruption. — This appears about the fourth day on the 
face, and rapidly spreads over the entire body. It is com- 
posed of small, dark-red, velvety papules, which form groups 



MEASLES. 261 

having crescentic borders. Red spots are frequently noticed 
on the pharynx before the eruption develops on the skin. In 
two or three days the eruption begins to fade, and branny 
desquamation soon follows. 

Malignant, or Hemorrhagic Measles. — This form occurs 
under bad hygienic conditions, and is characterized by a pete- 
chial rash, by hemorrhages from the mucous membranes, and 
by profound prostration. 

Complications and Sequels. — Capillary bronchitis, 
catarrhal pneumonia, tuberculosis, otitis, gastro-intestinal 
catarrh, cancrum oris, and paralysis. 

Diagnosis. Rbtheln. — Prodromes are often absent ; fever 
and catarrh are slight ; sore throat is marked. The rash 
appears on the first or second day as a diffuse red blush, or 
as small pale-red spots which do not form crescentic-shaped 
patches ; desquamation is scarcely noticeable. 

Scarlet Fever. — The fever is high and lacks the pre-eruptive 
remission ; sore throat is present instead of general catarrh ; 
the eruption appears on the first or second day as a diffuse 
punctiform rash ; the pulse is out of proportion to the fever ; 
and there is much greater tendency to nephritis. 

Prognosis. — Guardedly favorable. Complications are apt 
to occur and render the prognosis grave. 

Treatment. — Isolation . A darkened well-ventilated room ; 
absolute rest. A liquid diet. Such refrigerant remedies as 
sweet spirits of nitre and liquor amnionic acetatis are indicated 
and may be combined with a little aconite. 

T$l Spt. aether, nitrosi, fgss ; 

Liq. amnion, acetatis, q. s. ad f^iij. — M. 
Sig. — A teaspoonful every two hours. 

For the bronchial catarrh, apply a cotton jacket to the chest 
and give internally expectorants with sedatives like paregoric 
or bromide of potassium. 

]£ Liq. ammon. acetat., f^ss ; 
Syr. ipecac, f^j ; 

Liq. raorph. sulph. (U. S. P.), mxl ; 
Syr. acacise, f^j. 

Aquae, f^iss. — M. (Meigs and Pepper.) 
Sig. — A teaspoonful every two hours for a child of two years. 



262 ACUTE INFECTIOUS DISEASES. 

Gastric irritability should be relieved by small doses of bis- 
muth or by calomel and soda. During desquamation the skin 
should be anointed two or three times daily. High fever is 
best controlled by sponging with tepid water. During con- 
valescence nutrients like cod-liver oil and malt, and tonics like 
iron, quinine, and strychnia are indicated. 

ROTHELN. 

(Rubella, German Measles, Epidemic Roseola.) 

Definition. — An acute contagious disease resembling both 
scarlet fever and measles, but differing from these in its short 
course, slight fever, and freedom from sequelae. 

Etiology. — The disease is highly contagious, and the 
poison may be carried on clothes or other fomites. It gener- 
ally occurs in epidemics, but sporadic cases are not uncommon. 
It is most frequently observed in children, but unprotected 
adults are not exempt. One attack usually protects from 
another, but not from measles or scarlet fever. 

Period of Incubation. — About two weeks. 

Symptoms. — Prodromes are slight, or altogether absent. 
The disease begins with drowsiness, slight fever, and sore 
throat, The eruption appears on the first or second day, and 
varies considerably in its character. In some cases the rash 
is composed of pale-red, scarcely elevated papules, which are 
more or less discrete {rubella morbilUforme) ; in others the rash 
is bright red and diffuse like that of scarlet fever {rubella scar- 
latiniforme). It begins on the face and rapidly spreads over 
the entire body, but it fades so rapidly that the face may be 
clear before the extremities are affected. Slight desquamation 
frequently follows, though it is often absent. Apart from the 
sore throat, the catarrhal symptoms are slight. The super- 
ficial cervical and posterior auricular glands are more swollen 
than in measles. 

The duration is from three to five days. 

Prognosis. — Good. Complications are rare. 

Treatment. — Rest. Liquid diet. Refrigerants. Spong- 
ing with tepid water. 






SMALLPOX. 



263 



SMALLPOX. 

(Variola.) 

Definition. — -An acute contagious disease, characterized by 
vomiting ; lumbar pains; an eruption which is at first papular, 
then vesicular, and finally pustular ; and by fever which is 
marked by a distinct remission beginning with the advent of 
the eruption, and lasting until the latter becomes pustular. 

Etiology. — The poison of smallpox is extremely tenacious ; 
it may remain latent in clothes or other fomites for a long time, 
and then be capable of exciting the disease. The virulent 
principle is doubtless contained in the pustules and in all the 
excretions of the body, but it has not been isolated. Unless 
protected by vaccination or a previous attack, nearly every one 
is susceptible, from the aged to the child in utero. The colored 
race seem especially predisposed. 

Pathology. — The eruption consists in an infiltration of 
cells into the rete mucosum or into the true skin. The cells 
ultimately undergo liquefaction-necrosis, when suppuration 
soon follows. Genuine pocks are frequently found in the 
motith, oesophagus, and larynx, and rarely in the stomach, 
trachea, and bronchi. The spleen is engorged. The organs 
and muscles reveal fatty and parenchymatous degeneration. 

Varieties. — Discrete ; confluent ; malignant ; varioloid. 

Fig. 21. 




Temperature Curve in Smallpox. 

Symptoms. Discrete Smallpox. — The disease usually 
begins with a chill or series of chills, followed by vomiting and 
intense lumbar pains. The fever rises rapidly, reaching its 



264 ACUTE INFECTIOUS DISEASES. 

maximum (104°— 105°) in forty-eight hours, and continues 
high until the third or fourth day, when it falls several degrees ; 
this remission lasts until the seventh or eighth day, — that is, 
the time of pustulation, — when it again rises. The secondary 
or suppurative fever shows marked fluctuations ; its height is 
proportionate to the number of pustules ; and it falls by lysis 
about the eighteenth day of the disease. The pulse is full and 
rapid (120-140) ; the breathing is hurried; the skin is dry ; 
the bowels are usually constipated, though diarrhoea is not un- 
common; and the urine is scanty and frequently albuminous. 

The Eruption. — About the third or fourth day small red 
spots are noticed on the forehead, face, and wrists ; these are 
rapidly converted into smooth round papules which feel like 
shot under the skin. The eruption rapidly spreads over the 
entire body. About the third day the papules are converted 
into clear vesicles, which present a depression or umbilication 
at their summit. They are also loculated, i. e. divided into 
compartments by fibrinous partitions, so that when pricked 
with a needle all of the contained fluid does not escape. In 
two or three days the clear fluid becomes turbid and the 
vesicles are gradually converted into pustules. The latter 
soon lose the umbilicated appearance. Between the lesions 
the skin is oedematous, so that the body is swollen and the 
features are unrecognizable. In three days more the pustules 
dry up, or break and form soft yellow crusts which exhale a' 
peculiar, offensive odor ; they adhere to the skin for a week or 
more. When the scabs fall off, scars, or pock-marks generally 
remain, constituting a permanent deformity. 

At the beginning of the disease, before the true variolous 
eruption appears, either a red blush or a macular rash is often 
observed on the inner side of the arms and thighs. 

Confluent Smallpox. — The papules are abundant, and soon 
coalesce. The extremities are swollen and painful. The 
secondary fever is very high and irregular. True pocks nearly 
always develop in the air-passages and give rise to a copious 
fetid discharge from the nose and throat, to hoarseness, and to 
cough. Delirium, stupor, and subsultus are frequent symp 1 
toms. If the patient recovers, it is after a tedious con- 



SMALLPOX. 265 

valescenee, with great facial disfigurement, and often with 
defective vision and hearing. 

Malignant Smallpox. — In some cases the disease is ushered 
in with high fever, lumbar pains, and great prostration. Soon 
ecchymoses appear on the skin ; bleeding from the mucous 
membranes follows ; and death results before a true variolous 
rash appears. In other cases the disease advances like or- 
dinary smallpox up to the pustular stage ; then the pustules 
become effused with blood, and bleeding from the mucous 
membrane follows. This form is also very fatal. 

Varioloid, — This is modified smallpox occurring in one who 
has been partially protected by previous vaccination. The 
symptoms are mild ; the eruption resembles that of common 
smallpox, but is usually very scant ; secondary fever is 
absent. 

Complications and Sequels. — ■Broncho-pneumonia; 
pleurisy ; inflammations of the eye (keratitis, iritis, conjunc- 
tivitis) ; otitis ; arthritis ; and boils. 

Diagnosis. Varicella. — The symptoms are milder; pro- 
dromes are generally absent ; the eruption appears earlier, is 
more superficial, lacks an inflammatory areola, and is not 
umbilicated. 

Secondary Syphilis. — The history ; the absence of fever ; 
the symmetrical distribution of the eruption ; its dark- 
coppery color ; its polymorphous character (papules, vesicles, 
and pustules associated in a limited area) ; and the absence 
of itching will indicate syphilis. 

Prognosis. — This depends upon the virulence of the epi- 
demic, the degree of protection by vaccination, and the amount 
of the eruption. In discrete cases, it is generally favorable ; 
in the confluent, grave ; in the malignant, almost hopeless. 

Treatment. — The prophylactic treatment consists in vac- 
cination. 

The Attack. — Isolation. Every precaution must be taken to 
prevent the spread of the disease. The other members of the 
family should be vaccinated at once. The room should be 
cool and well ventilated. The diet must be liquid or semi- 
liquid, and may consist of milk, meat broths, eggs, etc. The free 
use of water, lemonade, or soda-water should be encouraged. 



266 ACUTE INFECTIOUS DISEASES. 

The intense lumbar pains should be relieved by opium and the 
application of hot-water bags. Gastric irritability may call 
for bismuth or calomel and soda. The naso-pharynx should 
be kept clean by antiseptic washes and sprays, and DobelPs 
solution, dilute listerine, or dilute peroxide of hydrogen may 
be used for this purpose. The eyes must be kept clean by 
being washed several times a day with a saturated solution of 
boric acid. Stimulants are often indicated. High fever may 
be controlled by antipyrin or phenacetin, or by the cold pack 
or cold bath. 

The prevention of Pitting. — The room should be darkened, 
and the exposed parts covered with cloths soaked in dilute 
carbolic acid or bichloride of mercury, or with masks upon 
which has been spread some simple ointment, as one of mercury 
or of zinc. Unfortunately, when the lesions are deeply situ- 
ated there is no means of preventing pitting. The separation 
of the scabs may be facilitated by the use of warm baths. 

VARICELLA. 

(Chicken-pox.) 

Definition. — An acute contagious disease of short duration, 
characterized by slight fever and a discrete vesicular eruption, 
which disappears in two or three days by desiccation. 

Etiology. — The disease occurs sporadically and epidemi- 
cally. It is observed chiefly in children, but adults are not 
exempt. One attack usually protects from others. It bears 
no relation to smallpox. 

Period of Incubation. — One to two weeks. 

Symptoms. — Slight fever and the appearance of a vesicular 
eruption within the first twenty-four hours. The vesicles ap- 
pear in crops over two or three days ; they are superficial, not 
umbilicated, and lack the red areola which is seen around the 
vesicle of variola. They rarely become pustular, and are only 
occasionally followed by scars. The duration is about a week. 

Diagnosis. Smallpox. — The slight fever ; the absence of 
lumbar pains; the early appearance of the eruption ; and the 
absence of the shot-like feel, umbilication, and red areola will 
serve to distinguish varicella from smallpox. 



VACCINIA. 267 

Prognosis. — Always favorable. 

Treatment. — Rest in bed. A light diet. The application 
of some sedative lotion or ointment to allay itching and to pre- 
vent scratching. 



-&■ 



VACCINIA. 

(Vaccination, Cow-pox.) 

Definition. — A general disease with a local manifestation 
resembling the pock of variola, and acquired by inoculation 
with the virus of cow-pox. 

History and Object. — The value of vaccination as a 
means of protection against smallpox was first made known 
to the world in a paper published by Edward Jenner in 1798. 

Recent vaccination gives almost complete immunity from 
variola ; the mortality of smallpox acquired after vaccination 
is almost inversely proportionate to the number of true vac- 
cine scars. 

Etiology. — Vaccinia is induced by inoculating the arm 
with fresh virus obtained from the udder of a calf suffering 
from cow-pox (bovine virus), or from the vesicle of a patient 
who has already been vaccinated (humanized virus). The 
former is preferable on account of the readiness with which the 
fresh article can be obtained, and on account of its freedom 
from other poisons, like syphilis. 

Time of Performance. — The first vaccination should be 
made about the third month, the second at the seventh year, 
and the third at puberty. It should always be repeated when 
smallpox is prevalent.. 

Performance of Vaccination.— The arm should be ren- 
dered aseptic, and the skin scratched with a lancet or with the 
i^ory point containing the lymph until red serum begins to 
ooze, when the moistened virus should be carefully worked in. 
The spot must be carefully protected from the clothes until 
thoroughly dry. 

Symptoms. — About the second or third day after the opera- 
tion a papule surrounded by a red areola forms at the seat of 
"^oculation. In two or three days the papule is converted 
Mo a clear vesicle, which is umbilicated at its summit; the 



268 ACUTE INFECTIOUS DISEASES. 

surrounding tissues are red, tender, and considerably infiltrated. 
About the seventh or eighth day the vesicle becomes a pustule ; 
this lasts until the twelfth day, when it dries up and forms a 
scab, which separates during the third week and leaves behind 
a pitted scar. During the course of the eruption there are 
slight fever, malaise, restlessness, and enlargement of the 
axillary glands. 

Complications. — Erysipelas, abscess, and various cutaneous 
eruptions. Syphilis has occasionally been transmitted through 
humanized virus. 

ERYSIPELAS. 

(St. Anthony's Fire.) 

Definition. — An acute contagious disease excited by 
streptococci, and characterized by a peculiar inflammation of 
the skin and subcutaneous tissue, irregular fever, and a ten- 
dency to relapse. 

Etiology. — The disease is somewhat contagious and the 
poison can be carried in fomites. Certain families and certain 
individuals seem particularly predisposed. Puerperal women 
and w T ounded persons are very susceptible. Diseases which 
lower the vitality, especially Bright' s disease, predispose. One 
attack does not protect against a recurrence, but rather favors 
it. Erysipelas was formerly divided into traumatic and idio- 
pathic varieties ; but the two are identical, and it is probable 
that in those cases in which there is no conspicuous wound 
there is a slight abrasion through which the poison gains ad- 
mittance. 

The exciting cause is doubtless the streptococcus pyogenes. 

Pathology. — Erysipelas most frequently manifests itself 
on the face. The part is bright red in color, swollen, in- 
durated, and sharply circumscribed. The various strata of the 
skin are infiltrated with serum, and leucocytes and streptococci 
are found in the lymph-spaces. In severe cases the inflam- 
matory products are converted into pus, and abscesses form. 

Period of Incubation. — Three to seven days. 

Symptoms. — Prodromes are sometimes present, and consist 
of slight fever, chilliness, malaise, tingling of the part to be 



ERYSIPELAS. 269 

affected, and sometimes enlargement of neighboring lymphatic 
glands. In many cases the disease is ushered in suddenly 
with a chill, followed by pain in the head and limbs and a 
high, irregular fever. The temperature may reach 103° or 
104° in twelve or twenty-four hours. The pulse is full and 
rapid ; the tongue is heavily coated ; the appetite is lost ; the 
bowels are constipated ; and the urine is scanty and often 
slightly albuminous. 

Local Phenomena. — The inflammation usually begins in the 
neighborhood of the nose, and spreads upward and laterally over 
the head to the neck, where it frequently stops. The affected 
part has a crimson hue ; it is swollen and tense, and frequently 
ends in a sharply-defined ridge, beyond which, however, pro- 
jections can be felt advancing into the subcutaneous tissue. 
The surface of the inflamed patch is at first smooth and glazed, 
but later it is covered with minute vesicles or blebs. The patient 
complains of burning and tingling ; the surrounding parts are 
extremely cedematous, so that the features may be scarcely 
recognizable. In four or five days the redness begins to fade 
and the swelling to subside ; desquamation follows ; the general 
symptoms improve ; and the fever falls by crisis. The average 
duration is from a week to ten days. Relapses are extremely 
common. 

Erysipelas Ambulans. — Sometimes the inflammation disap- 
pears in one place and reappears in another, and so continues 
indefinitely. In such cases typhoid symptoms, such as mut- 
tering delirium, a brown, fissured tongue, and subsultus ten- 
dinum, develop. 

Complications. — Inflammation of serous membranes 
(pericarditis, pleuritis, meningitis), oedema of the larynx, ne- 
phritis, hyperpyrexia, ulcerative endocarditis, and septicaemia. 

Diagnosis. Erythema. — The absence of high fever, of 
marked swelling, and of an abrupt ridge will serve to dis- 
tinguish erythema from erysipelas. 

Acute Eczema. — The swelling is less marked ; the itching is 
intense; the sweFing and redness are not circumscribed, but 
shade gradually into healthy tissue ; and there is no fever. 

Prognosis. — In the robust the prognosis is favorable. In 
the old, in alcoholic subjects, and in those suffering from 



270 ACUTE INFECTIOUS DISEASES. 

chronic nephritis, the prognosis must be guarded. Ambulatory 
erysipelas may kill by exhaustion. 

Treatment. — Isolation ; absolute rest ; a nutritious diet. 
It is well to begin the treatment with a saline or mercurial 
laxative. The tincture of the chloride of iron seems to exert 
a beneficial influence ; it may be given in doses of twenty 
drops every two hours. Quinine (gr. v thrice daily) is also 
useful. When there is much restlessness and insomnia, bro- 
mide of potassium, chloral, or opium may be administered. 

Local Treatment. — One of the following applications maybe 
employed : Cloths wrung out in a solution of bichloride of 
mercury (1-5000), or in a saturated solution of boric acid, or in 
lead-w r ater and laudanum : a dusting powder of starch and 
oxide of zinc ; or an ointment of ichthyol. 

tyi Plumbi acetatis, £j ; 
Tinct. opii, f ,^j ; 
Aqure, q. s. Oj. — M. 
Sig. — Shake well and apply on lint. 

Or— 

J$t Ichthyol, | ss ; 
Vaselin., 3 ij. — M. 
Sig. — Spread thickly on lint and apply to the affected part. 

The injection of antiseptic remedies around the inflammatory 
patch, with the view of preventing its spread, is very painful 
and rarely necessary. 

YELLOW FEVER. 

Definition. — An acute infectious disease, characterized by 
jaundice, epigastric tenderness, vomiting, hemorrhages, and a 
febrile course consisting of two paroxysms. 

Etiology. — A hot climate and a warm season, salt water, 
bad drainage, and overcrowding favor the development of 
epidemics. The disease is not distinctly contagious ; the 
poison probably undergoes some changes outside of the body, 
and is carried through the atmosphere, clothes, or other 
fomites. The colored race are more susceptible than the 
white. Strangers in an infected district are more liable to be 



YELLOW FEVER. 271 

attacked than residents. One attack usually confers immunity 
from others. 

Pathology. — The tissues are stained yellow by disin- 
tegrated blood (hematogenous jaundice). The liver is pale 
and is the seat of extensive fatty degeneration. The gastric 
mucous membrane is swollen, congested, and frequently ecchy- 
mosed. The spleen is not enlarged. The heart is pale and 
flabby. The kidneys are generally the seat of parenchymatous 
inflammation. 

Period of Incubation. — A few hours to a week. 

Symptoms. First Stage. — The disease begins with a chill, 
followed by pain in the head, back, and limbs. The tempera- 
ture rises rapidly until it reaches its maximum (103°-105°). 
The face is flushed, the conjunctive are injected, and the 
pupils small ; the tongue is coated, the epigastrium is tender, 
the stomach is irritable and unretentive ; the bowels are con- 
stipated j* and the urine is scanty and albuminous. This stage 
lasts from a few hours to several days, and is followed by a 
marked fall in the temperature and an improvement in the 
general symptoms (stage of remission). At this time con- 
valescence may begin, or the patient may pass into the second 
febrile paroxysm. 

Second Stage. — The fever rises to its original height; the 
skin becomes yellow; vomiting is persistent, and the ejected 
material may contain dark blood (" black vomit"). Hemor- 
rhages sometimes occur from other mucous membranes. The 
pulse is rapid, though not proportionate to the fever. The 
urine becomes very scanty and contains albumin and casts. 
Death frequently results from exhaustion or uraemia, though 
recovery may follow the gravest symptoms. 

Duration. — From a few hours to a week. 

Diagnosis. Relapsing Fever. — This is distinguished by 
the enlargement of the spleen, the multiple paroxysms, the 
spirilli in the blood, and the absence of black vomit. 

Acute Yellow Atrophy of the Liver. — The early appearance 
of jaundice, the diminution in the size of the liver, the slight 
fever, the marked cerebral symptoms, aud the presence of 
leucin and tyrosin in the urine will indicate acute yellow 
atrophy. 



272 acute infectious diseases. 

Remittent Fever. — This may be distinguished by the enlarge- 
ment of the spleen, the multiple remissions, the presence in the 
blood of ksematozoa of Laveran, and by the absence of black 
vomit. 

Prognosis. — Always grave. The average mortality in 
different epidemics is from twenty to seventy per cent. In 
individual cases, high fever, severe cerebral symptoms, black 
vomit, and suppression of urine are unfavorable features. 

Treatment. — Absolute rest. A cool, well-ventilated room. 
A liquid diet. The pains in the back and limbs may be re- 
lieved by hot- water bags and the administration of morphia. 
Fur the gastric irritability a mustard plaster may be applied 
to the epigastrium, and cracked ice, iced champagne, carbolic 
acid, or small doses of calomel may be given internally. Stim- 
ulants are frequently indicated. Quinine may be given by 
the rectum. High fever is best controlled by the external 
application of cold. The black vomit results from blood- 
dyscrasia, and while such remedies as gallic acid, Monsel's 
solution, ergot, and turpentine are recommended, they usually 
prove useless. 

ACUTE GENERAL TUBERCULOSIS. 

(Acute Miliary Tuberculosis.) 

Definition. — An acute infectious disease excited by the 
tubercle bacillus, and characterized anatomically by the 
simultaneous formation of miliary tubercles in many parts of 
the body. 

Etiology. — -The disease usually develops in early adult 
life. Certain infectious diseases like measles, whooping-cough, 
and typhoid fever seem to predispose. General tuberculosis 
is almost always secondary to local tuberculosis— pulmonary 
phthisis or a scrofulous lymphatic gland. The bacilli are 
probably disseminated by the veins. 

Pathology. — All the organs may be uniformly infiltrated 
with discrete tubercles, but more commonly certain organs, 
like the brain and lungs, are more affected than others. 

Symptoms. — Debility ; loss of flesh and strength ; fever 
moderately high (102°-! 04°), irregular, and marked by evening 



ACUTE GENERAL TUBERCULOSIS. 273 

exacerbations and morning remissions ; cough ; hurried respi- 
rations ; a brown, fissured tongue ; a weak, rapid pulse ; en- 
largement of the spleen; delirium; subsultus tendinum ; and 
stupor. 

Tubercle bacilli are rarely found in the expectoration or in 
the blood. 

The duration is from two to four weeks. 

When the lungs are chiefly affected there are : Dyspnoea, 
marked cough, muco-purulent and bloody expectoration, 
cyanosis, sibilant and subcrepitant rales, and perhaps areas 
over which bronchial breathing is detected. 

When the meninges are chiefly affected there are : Intense 
headache, convulsive seizures, photophobia, delirium, facial 
palsies, stupor, coma, and Cheyne-Stokes breathing. Tubercles 
may be detected on the retina. 

When the intestines and peritoneum are affected there are : 
Pain, tenderness, abdominal distention, and diarrhoea. 

Diagnosis. — The disease closely resembles typhoid fever, 
and there is no doubt that the mortality of the latter is en- 
hanced by included cases of unsuspected general tuberculosis. 

The following table will indicate the points of distinction :— 



Typhoid Fever. 

Epistaxis common. 
The temperature rises gradually, 
and runs a regular course. 



Acute General Tuber- 
culosis. 

Infrequent. 

The temperature usually rises 
abruptly, and runs a very ir- 
regular course. 

Infrequent. 

Rarely present 



Diarrhoea is frequent. 

An eruption is generally present. 

"No tubercles on the retina. ! Occasionally detected. 

Respirations are hurried. j Still more hurried. 

Facial palsies are rare. i Common. 

Prognosis. — Always fatal. 

Treatment. — Palliative. The diet should consist of milk, 
eggs, and broths. Stimulants are indicated. High fever 
should be controlled by antipyrin or by the external applica- 
tion of cold. 

18 



274 ACUTE INFECTIOUS DISEASES. 

DIPHTHERIA. 

(Diphtheritis, Malignant Sore Throat, Cynanche Contagiosa.) 

Definition. — An acute contagious disease excited by the 
Klebs-Lofler bacillus, and characterized by moderate fever, 
glandular enlargements, great prostration, and a fibrinous exu- 
dation which is usually located in the throat. 

Etiology. — Childhood (between three and six), defective 
drainage, and catarrhal conditions of the throat are predispos- 
ing factors. The poison is contained in the secretions of the 
throat, and may be transmitted through the atmosphere or 
through fomites. One attack does not protect from another, 
but rather predisposes. 

The exciting cause is the Klebs-Lofler bacillus, which is 
found only in the membranous exudation. The constitutional 
symptoms result from the poison generated by the bacillus. 

Pathology. — The false membrane is usually found on the 
tonsils, pillars, and pharynx, but it may extend to the mouth, 
larynx, or nose. The bacillus coming in contact with the 
throat leads to the death of the superficial cells, which ulti- 
mately undergo coagulation-necrosis. The irritation causes 
a migration of leucocytes, and these undergo a similar necrosis. 
The membrane thus formed is of a grayish-white color, and is 
more or less adherent, so that when torn off it leaves a raw 
surface. Sometimes the necrosis extends to the deeper tissues 
and causes widespread ulceration aud even gangrene. Micro- 
scopically, the pseudo-membrane is composed of fibrin, leuco- 
cytes, bacteria, and the remains of epithelial cells. The lym- 
phatic glands are considerably swollen. The spleen is 
engorged. The various organs and the muscles reveal fatty 
and parenchymatous degeneration. Examination of the lungs 
frequently shows capillary bronchitis, catarrhal pneumonia, 
and collapse. 

In some cases the blood is dark and fluid, while in others 
firm clots are often found within the heart. 

Types. — Diphtheria may be divided according to the loca- 
tion of the exudate into: (1) Faucial ; (2) laryngeal; (3) 
nasal ; (4) cutaneous. According to the severity of the attack 
it may be divided into: (1) Mild; (2) grave; (3) malignant. 



DIPHTHERIA. 275 

Period of Incubation. — Two to ten days. 

Symptoms. Fancied Diphtheria. — The disease commonly 
begins with chills, moderate fever, malaise, and sore throat. 
The fever, as a rule, is not very high (102°-104°) and its 
course is quite irregular. The pulse soon becomes rapid and 
feeble ; the bowels are constipated ; the urine is scanty and 
frequently albuminous ; and the prostration and pallor are often 
out of all proportion to the severity of the febrile symptoms. 

Local Phenomena. — The child complains of difficult swallow- 
ing ; the muscles of the neck feel stiff; there is tenderness 
under the jaw ; the lymphatic glands are considerably swollen ; 
and the fauces are covered with a grayish-white membrane 
which when stripped off leaves a raw bleeding surface, and is 
soon followed by a similar deposit. The membrane may 
spread to the nose or larynx. 

The course of the disease is indefinite, the average duration 
being from one to two weeks. 

Laryngeal Diphtheria. — This is usually secondary by exten- 
sion from the fauces, but it is occasionally primary. It is rec- 
ognized by hoarseness or aphonia, croupy cough, progressive 
dyspnoea, and stridulous breathing. The aire of the nose play ; 
the sterno-cleido-mastoids are prominent; the supra-sternal 
notch is deepened ; and the base of the chest is retracted. 
Shreds of false membrane are sometimes expectorated in the 
violent fits of coughing. The febrile symptoms are usually 
slight. Death frequently results from suffocation, and recovery 
without operation is unusual. 

Nasal Diphtheria. — This is nearly always secondary. It 
is recognized by grave constitutional symptoms — high fever, 
marked glandular involvement, and great prostration ; by an 
offensive discharge from the nose ; by epistaxis ; and by ex- 
coriation of the lips. The false membrane may be detected 
on inspection. 

Cutaneous Diphtheria. — This form may be primary or 
secondary. The constitutional symptoms are similar to those 
of faucial diphtheria. 

Complications and Sequel.e. — Capillary bronchitis, 
catarrhal pneumonia, pulmonary collapse, endocarditis, heart- 
clot, nephritis, and paralysis.. 



276 ACUTE INFECTIOUS DISEASES. 

Diphtheritic Paralysis. — This generally occurs during con- 
valescence and is observed in about fifteen per cent, of all cases. 
There is no relation between the severity of the attack of 
diphtheria and the liability to paralysis ; mild cases, which are 
thought to be simple pharyngitis, are sometimes followed by 
troublesome paralysis. The pharynx is the most common 
seat, and the palsy is recognized by difficult swallowing and 
the regurgitation of liquids through the nose. Next in fre- 
quency the eyes are involved, and strabismus or ptosis de- 
velops. The heart may be affected, and if sudden death does 
not result, the condition may be manifested by a remarkable 
slowing of the pulse. The extremities are rarely paralyzed. 
The paralysis is due to a toxic neuritis. 

Diagnosis. Scarlet Fever. — The onset is more sudden ; 
the fever is high ; the pulse more rapid ; the tongue presents a 
strawberry appearance ; a red punctiform rash appears on the 
first or second day ; and membrane is not often found in the 
throat. 

Membranous Croup. — Laryngeal diphtheria is generally 
secondary to faucial diphtheria ; it is contagious ; it is often 
epidemic ; it is associated with greater constitutional dis- 
turbance ; and it is more apt to be followed by sequelae. 

Prognosis. — Always guarded. The mortality varies in 
different epidemics from 10 to 50 per cent. When the con- 
stitutional symptoms are mild, and the membrane is confined 
to the fauces and shows little tendency to spread, the prognosis 
is quite favorable. Nasal diphtheria is always a grave disease. 
Laryngeal diphtheria proves fatal in 60 or 70 per cent, of all 
cases. 

Treatment. — Isolation. Absolute rest. A nutritious diet 
consisting of milk, koumiss, eggs, broths, and the like. Stimu- 
lants are nearly always required, and should be administered 
as soon as the pulse softens. Tonics like iron, quinine, and 
mineral acids are useful when well borne. Of the special 
remedies, mercury is the most reliable, and either calomel or 
the bichloride may be employed. 

fy. Hydrarg. chlor. mit., gr. j ; 
Sodii bicarb., gr. xxiv ; 
Pulv. aromat.,' gr. vj.— M. (Starr,) 
Et ft. in chart. No, xii. 
Sig.— One powder every two hours. 



DIPHTHERIA. 277 

Or— 

fy. Hydrarg. chlor. corros., gr. j ; 
Spt. vini rect., f^ij ; 
Elix. bismuth, et pepsin., ad f^iv. — M. 

(J. Lewis Smith.) 
Sig.— Teaspoonful every two hours for a child of six years. 

Iron may be given with the bichloride, as in the following 
mixture : — 

J$l Hydrarg. chlor. corros., gr. j ; 
Tinct. ferri chlor., 
Spt. vini rect., aa f^ij ; 
Syr. limonis, 
Aquae, aa f^ij. — M. 
Sig. — Teaspoonful every two or three hours for a child of six 
years. 

The atmosphere of the room should be rendered moist bx 
slacking lime, by evaporating water on the stove or over a 
spirit-lamp, or by means of a steam atomizer. The addition 
of turpentine or of oil of eucalyptus to the water is often rec- 
ommended. Iodine, or an ointment of mercury, belladonna, 
or ichthyol, may be applied to the swollen and tender glands. 
The naso-pharynx should be kept clean by antiseptic sprays 
or douches, and one of the following may be selected for this 
purpose : Dobell's solution, dilute listerine, or dilute peroxide 
of hydrogen. 

Many solvents have been recommended ; those most com- 
monly employed are dilute lactic acid, dilute hydrochloric 
acid with pepsin, a solution of papayotin, an alkaline solution 
of trypsin, and peroxide of hydrogen. The last is often ex- 
tremely useful, but it is essential that it should be fresh. 

fy Hydrogen peroxide (Marchand), f^j ; 
Glycerin, f^ij ; 
Aquse destil., f.^ss. — M. 
Sig. — Use as a spray or mop. 

When the throat is not too sensitive, the peroxide of hy- 
drogen may be employed undiluted. 

In laryngeal diphtheria, when these means fail, tracheotomy 
or intubation must be resorted to. 



278 ACUTE INFECTIOUS DISEASES. 

WHOOPING-COUGH. 

(Pertussis.) 

Definition. — An infectious disease, characterized by 
catarrh of the respiratory tract and peculiar paroxysms of 
cough ending in prolonged crowing or whooping inspiration. 

Etiology. — The disease occurs both sporadically and epi- 
demically. It is most frequently met with in children, but 
unprotected adults are not exempt. The disease is unquestion- 
ably contagious, and the virus seems to be associated with the 
sputum. One attack protects from others. 

Pathology. — Xo characteristic lesions are observed after 
death. The poison excites an inflammation of the respiratory 
mucous membrane, and probably irritates the peripheral fila- 
ments of the pneumogastric nerve, and so causes the parox- 
ysmal cough. In fatal cases, pulmonary complications are 
usually discovered, such as catarrhal pneumonia, pulmonary 
collapse, and emphysema. 

Symptoms. — There are three stages : (1) The catarrhal 
stage; (2) the paroxysmal stage; and (3) the stage of decline. 

Catarrhal Stage. — The disease begins with the symptoms of 
coryza, and bronchial catarrh — slight fever, sneezing, running 
from the nose, dry cough, and rales. But it does not respond 
to the ordinary remedies for catarrh, and after lasting one or 
two weeks passes into the paroxysmal stage. 

Paroxysmal Stage. — The cough becomes more violent and 
paroxysmal. During the paroxysm the face is cyanosed, the 
eyes are injected, and the veins distended. The cough fre- 
quently induces vomiting, and, in severe cases, epistaxis or 
other hemorrhages. The close of the paroxysm is marked by 
a long-drawn, shrill, whooping inspiration due to the spas- 
modic closure of the glottis. 

The number of paroxysms, or " kinks," varies from ten or 
twelve to forty or fifty in the twenty-four hours. From the 
forcible propulsion of the tongue against the lower incisors, 
an ulcer is frequently formed on the frseimm. The duration 
of this stage is three or four weeks. 

Stage of Decline. — The paroxysms grow less frequent and 



WHOOPING-COUGH. 279 

less violent and finally cease. Protracted cases are followed 
by anaemia and prostration. 

Duration. — The entire duration of the disease is from a 
few weeks to four months. 

Complications and Sequelae. — Catarrhal pneumonia, 
pulmonary collapse, emphysema, hemorrhage into the conjunc- 
tiva, ear, or brain, and convulsions. Grave cases are some- 
times followed by chronic bronchitis, tuberculosis, or cancrum 
oris. 

Diagnosis. — This can rarely be made with certainty during 
the catarrhal stage. Later, the paroxysmal cough ending in 
vomiting or in whooping is absolutely diagnostic. 

Prognosis. — Guardedly favorable. Severe cases in the 
young and debilitated not infrequently prove fatal. 

Treatment. — The child should be clad in flannel under-- 
clothes and carefully protected from changes of temperature. 
During the catarrhal or febrile stage the patient should be con- 
fined to bed. The diet should be light and nutritious. Coun- 
ter-irritants, like iodine, applied to the chest seem useful. 
Quinine is a reliable tonic and may be employed throughout 
the disease. The ordinary expectorant mixtures are valueless. 
Local applications to the respiratory mucous membrane give 
much relief. One of the following remedies may be inhaled : 
Creasote and chloroform, dilute peroxide of hydrogen, or a 
solution of menthol. 

I£ Menthol, gr. xx ; 

Liq. vaseline, f^j. — M. 
Sig. — Spray the nasopharynx and inhale several times a day. 

In very young children a solution of menthol may be in- 
haled from a cloth held under the chin. When paroxysms are 
violent the inhalation of a few drops of nitrite of amyl is de- 
sirable. 

The following antispasmodic remedies appear to lessen the 
severity and the frequency of the paroxysms : belladonna, anti- 
pyrin, asafcetida, and bromide of potassium. 

T$l Sodii bromidi, giss ; 
Tinct. belladounse, f^j ; 
Glycerine, f^ss ; 
Aquae, q. s. ad f^ss. — AI. 
Sig. — A teaspoonful every three or four hours. 



280 ACUTE INFECTIOUS DISEASES. 

Or— 

J$l Antipyrin, gr. xxxij ; 

Syr. tolutan., f$'\ ; 

Aquae q. s. ad f|ij. — M. 
Sig. — A teaspoonful every two or three hours. 

IXFLUENZA. 

(La Grippe, Catarrhal Fever, Epidemic Catarrh.) 

Definition. — An acute infectious disease, characterized by 
fever, extreme prostration, pain in the head and back, and 
generally by catarrh of the respiratory or gastro-intestinal 
tract. 

Etiology. — The disease occurs in epidemics which usually 
have their origin in Russia, whence they spread with wonder- 
ful rapidity over both continents. The exciting cause is still 
unknown, but the clinical history would lead to the inference 
that it is a microorganism. When prevalent, no age and 
neither sex is exempt. One attack does not confer immunity 
from others. 

Pathology. — Influenza does not often kill save by its 
complications. The latter are most frequently associated with 
the respiratory tract, and consist of capillary bronchitis, catar- 
rhal pneumonia, and croupous pneumonia. 

Symptoms. — The disease begins abruptly with lassitude, 
malaise, chilliness, severe pain in the head and back, fever 
ranging between 101° and 103°, and extreme prostration, 
which is out of proportion to the fever and any existing local 
inflammation. The catarrhal symptoms are injection of the 
eyes, sneezing, hoarseness, and hard paroxysmal cough. In 
simple cases the temperature falls in two or three days by 
crisis, but complications not infrequently prolong the case for 
several weeks. 

In some cases the catarrh of the respiratory tract is the 
chief feature ; in others the gastro-intestinal tract is attacked, 
and the symptoms resemble cholera morbus ; in a third group 
neuralgic pains in the head, back, and limbs are the most 
striking phenomena. 

Complications. — Catarrhal pneumonia, croupous pneu- 
monia, nephritis, neuritis, meningitis, and insanity. 



MUMPS. 281 

Diagnosis. Acute Bronchitis. — The fever is not so high • 
there is little or no prostration ; and the pains in the head and 
back are not nearly so marked as in influenza. 

Prognosis. — Uncomplicated cases nearly always recover. 
In the very old, and in those debilitated by chronic disease, 
influenza not infrequently proves fatal. 

Treatment. — Absolute rest in bed and a liquid diet. As 
there is no specific, the treatment is symptomatic. Quinine is a 
useful stimulant, and when the stomach is irritable it may be 
given by the rectum. 

The Pains. — Hot- water bags to the head and spine; 
morphia, or combinations of antipyrin or phenacetin with 
salol or salicin, thus : — 

fy Salol, 

Phenacetin, aa £ss. — M. 
Ft. in chart. No. xii. 
Sig. — One every two hours. 

Or— 

$. Quininse salicylate, gr. xl ; 
Phenacetin, £ss. — M. 
In 20 capsules. 
Sig. — One every two hours. 

Or— 

I£ Salicin, ^iij ; 

Phenacetin, gr. xvj ; 
Olei gaulther., gtt. xv ; 

Syr. acacise, f^vij.— M. (Curtin and Watson.) 
Sig. — Teaspoonful every hour or two. 

Heart-failure should be combated by alcohol and strychnia. 
Bronchial catarrh will require the remedies indicated in simple 
bronchitis. Sleep may be induced by opium, sulphonal, or 
bromide of potassium. 

MUMPS. 

(Epidemic Parotitis.) 

Definition. — An acute contagious disease, characterized 
by inflammation of the parotid and other salivary glands, 

Etiology. — The disease occurs sporadically and epidemi- 
cally. It is most frequently observed in young children, but 



282 ACUTE INFECTIOUS DISEASES. 

unprotected adults are not exempt. Males are more suscep- 
tible than females. The disease is highly contagious, and the 
virus is probably contained in the saliva, but it has not been 
isolated. One attack confers immunity from others. 

Pathology. — As the disease is so seldom fatal very little 
opportunity is afforded for studying its intimate pathology. 
The parotid glands are the seat of an inflammatory infiltration, 
but suppuration does not occur. The inflammation shows a 
marked tendency to leave the parotids and to involve the testes 
in the male, or more rarely the mamma? or ovaries in the female. 

Period of Incubation. — One to two w T eeks. 

Symptoms. — The disease is ushered in with chilliness, mal- 
aise, and moderate fever (101°-104°), followed by swelling 
of one parotid gland. The swelling is observed below and 
in front of the ear, is pyriform in shape, and has a doughy 
feel. The surrounding tissues are oedematons, the submaxil- 
lary glands are likewise swollen, and the features may be dis- 
torted beyond recognition. The movements of the jaw are 
restricted and painful. The saliva may be increased or di- 
minished. In many cases the other parotid becomes similarly 
affected. 

Often in the course of the disease the inflammation suddenly 
subsides in the parotid gland and reappears in the testicle in 
the male, or in the ovary or mamma in the female. 

The duration of the disease is usually five or six days. 

Complications. — Hyperpyrexia, metastasis to the testicle 
or ovary, and meningitis. Atrophy of the testicle rarely 
follows. 

Prognosis. — Favorable. 

Treatment. — Rest in bed. Mild febrifuges may be given 
internally. Locally, lead-water and laudanum, or some rube- 
facient liniment like the following, may be employed : — 

R Tinct. iodinii, 
Tinct. aconit. rad., 
Tinct. opii, aa fgij ; 

Liniment, chloroform., q. s. ad f^iij. — M. 
Sig. — Apply externally and cover with cotton- wool. 

The swollen testicle should be elevated and covered with 
lint saturated with lead-water and laudanum. If the swelling 






CHOLERA. 283 

persists, an ointment of mercury, belladonna, and ichthyol will 
be found useful. 

CHOLERA. 

(Asiatic Cholera, Epidemic Cholera, Malignant Cholera.) 

Definition. — An acute infectious disease, generally epi- 
demic, excited by Koch's comma-bacillus, and characterized 
by vomiting and purging of a serous material, painful cramps, 
and collapse. 

Etiology. — Cholera has its origin in India, and is carried 
thence to other parts of the world. The exciting cause is the 
comma-bacillus of Koch ; this usually has the form of a 
slightly-curved rod, but it is occasionally S-shaped. The rice- 
water evacuations only contain the bacilli, which, under favor- r 
able conditions, continue to grow outside of the body, and 
by gaining entrance into the healthy system propagate the 
disease. The disease always spreads along the lines of traffic, 
hence epidemics nearly always begin at the sea-coast and ex- 
tend inland. Cholera is slightly, if at all, contagious ; like 
typhoid fever, the poison is not carried through air, but chiefly 
through drinking-water. Laundresses and nurses, from their 
contact with the evacuations, readily acquire the disease. Epi- 
demics are more frequent in summer than in winter. No age 
is exempt, but the old are more susceptible than the young. 
The intemperate, the debilitated, and those suffering with gas- ' 
tro-intestinal catarrh are especially predisposed. 

Pathology.- — The body is shrivelled ; movements of the 
corpse are sometimes observed ; rigor mortis is marked and 
prolonged. The tissues are dry, and the large veins and right 
side of the heart contain thick, dark blood. The serous cavi- 
ties are empty and their surfaces sticky. The intestines con- 
tain more or less rice-water fluid, from which cultures of 
bacilli can be made. 

The mucous membrane has a pinkish color and is often the 
seat of ecchymoses ; the solitary and Peyer's glands are swol- 
len. Frequently extensive desquamation of the epithelial 
lining is observed, but this is usually regarded as a post-mor- 



284 ACUTE INFECTIOUS DISEASES. 

tern change. The kidneys reveal evidences of parenchymatous 
inflammation ; the liver is the seat of fatty degeneration. 

As the lesions are not sufficient to explain the clinical phe- 
nomena, it has been suggested by Koch that the bacilli create 
a poison the absorption of which causes the grave symptoms. 

Period of Incubation. — A few hours to several clays. 

Symptoms. — The severity of the symptoms varies consider- 
ably. In well-marked, but favorable, cases there are three 
stages : (1) Invasion ; (2) algid or collapse ; (3) reaction. 

Stage of Invasion. — The disease usually begins with malaise, 
headache, diarrhoea, rumbling noises in the intestines, and 
colic. Frequently these symptoms continue a few days and 
then subside; such cases are termed cholerine, and are as infec- 
tious as the fully-developed disease. 

Stage of Collapse. — The diarrhoea grows more marked ; the 
evacuations become copious, lose their feculent character, assume 
a rice-water appearance, and are discharged forcibly but with- 
out pain. Vomiting soon develops, and the ejected material 
resembles that passed by the bowel. Thirst is unquenchable. 
Severe cramps seize the muscles of the calves of the legs, thighs, 
arms, and abdomen. The surface is cold and covered with a 
clammy sweat ; the breath is cool ; the temperature in the 
axilla ranges from 95° to 85°, while in the rectum it may rise to 
103° or more. The voice is husky and finally reduced to a 
whisper ; the respirations are quickened ; the pulse becomes 
more and more feeble ; the body is livid and shrivelled ; the 
hands resemble those of a washerwoman ; the features are 
pinched and sometimes distorted ; the eyes are frightfully 
sunken. The urine is more or less suppressed, and the little 
that is passed generally contains albumin and a trace of sugar. 
Consciousness is usually retained until near the end, when coma 
sets in, 

The duration of this stage is from a few hours to two days. 

Stage of Reaction. — Sometimes, even when death seems im- 
minent, the surface-temperature begins to rise ; the urine in- 
creases ; the pulse strengthens ; the vomiting ceases ; the 
evacuations from the bowels become less frequent and begin 
to assume a feculent character, and convalescence is established. 

Occasionally, instead of convalescence, symptoms of a typhoid 



CHOLERA. 285 

type develop, such as moderate fever, a brown, fissured tongue, 
subsultus, muttering delirium, and coma. This condition, 
which is generally fatal, has been regarded as ursemic. 

Cholera Sicca. — In very violent cases collapse and death 
may follow without there having been any evacuation. After 
death the intestines contain rice-water fluid, which was not 
discharged during life probably on account of paralysis of the 
muscular coat of the bowel. 

Complications and Sequelje. — Nephritis, pneumonia, 
pleurisy, parotitis, ulceration of the cornea, diphtheritic in- 
flammation of the throat and fauces, abscesses, and local gan- 
grene. 

Diagnosis. Cholera Morbus. — This is always sporadic; 
the discharges are bilious in character ; a history of dietetic 
errors and of exposure can usually be obtained ; and the comma-' 
bacilli are not detected in the discharges. 

Prognosis. — Generally unfavorable. The mortality aver- 
ages about 50 per cent. In the old, young, debilitated, and 
intemperate it is very fatal. In individual cases, early col- 
lapse and a low surface temperature are unfavorable conditions. 

Treatment. Prevention. — This includes the isolation of 
the sick ; absolute cleanliness ; the disinfection of excreta and 
soiled bed-clothes; the thorough boiling of all water that is to 
be used for drinking purposes ; the use of a bland, unirritating 
diet ; the avoidance of overwork, exposure, and undue excite- 
ment ; and the prompt treatment of any gastro-intestinal dis- 
turbance that may arise. 

The Attack. — The violent vomiting and purging and the 
cramps call for morphia ; this is best administered hypoder- 
mically. There are no specifics. A remedy frequentlv recom- 
mended by competent observers is sulphuric acid, which may be 
given with laudanum or chlorodyne. Thirst is best assuaged 
by cracked ice ad libitum and acidulated drinks. For the 
vomiting a mustard poultice may be applied to the epigastrium, 
and iced champagne, carbolic acid, creasote, or dilute hydro- 
cyanic acid may be given internally. For the cramps the 
application of hot-water bags, warm fomentations, or the rub- 
bing in of warm oil may be useful ; when they are very severe 
a few whiffs of chloroform may be employed. When the pulse 



286 ACUTE INFECTIOUS DISEASES. 

weakens, stimulants like alcohol, ether, and ammonia should 
be given freely. 

Copious warm-water enemata containing laudanum and tan- 
nic acid have been recommended for the purging. 

The low temperature must be combated by the use of hot 
blankets, or, better still, by immersion in warm baths (98° to 
104°). In collapse, subcutaneous or intravenous injections of 
saline solutions have been highly recommended. The follow- 
ing solution, which is well spoken of by Fagge, may be 
injected directly into the veins, or may be allowed to flow 
through a rubber tube attached to an aspirating canula, and 
to enter the subcutaneous tissue by its own pressure : — 

^ Sodii phos., gr. iij ; 
Sodii chlorid., £j ; 
Potass, chlorid., gr. vj ; 
Sodii carb. , gr. xx ; 
Alcohol, f^ij ; 
Aqua? destil., f^xx.— M. 

The fluid should be warm, and the injection should be con- 
tinued until the pulse strengthens ; as much as eighty ounces 
may be introduced at one time. 

The diet should consist of the following : Light broths, milk 
with carbonated water, koumiss, wine-whey, thin gruels, and 
frozen blocks of beef-tea. 

TETANUS. 

(Lockjaw.) 

Definition. — An acute infectious disease excited by a 
special bacillus, and characterized by painful tonic spasms of 
the voluntary muscles. 

Etiology. — In the tropics, especially in the colored race, 
the disease often arises idiopathically. In temperate climates 
the poison nearly always gains entrance through a wound. 
Lacerated and punctured wounds, frost-bites, and burns are 
especially liable to become infected. Exposure to cold and 
wet after traumatism seems to predispose. Since the intro- 
duction of antiseptic surgery tetanus is less common than 
formerly. 



TETANUS. 287 

The exciting cause is a special microorganism — the tetanus 
bacillus. 

Pathology. — Congestion of the spinal cord and of the 
nerves leading to the wound. 

Symptoms. — The disease begins with a feeling of rigidity 
in the muscles of the neck and lower jaw ; by degrees the 
muscles of the back, abdomen, and lower extremities are 
similarly involved. The brow is wrinkled, the corners of the 
mouth are drawn upwards (risus sardonicus), the jaws are 
tightly closed (trismus) ; and the body becomes arched, the 
patient resting on his head and heels (opisthotonos). There is 
extreme hyperesthesia, so that the slightest touch causes a 
violent exacerbation of the spasm, which is attended by ex- 
cruciating pain. If the respiratory muscles are involved, there 
is intense dyspnoea. The temperature usually remains normal' 
until just before death, when it may rise to 107° or more. 
The mind is clear to the end. The duration is from a few 
days to several weeks. 

Diagnosis. Strychnia-poisoning. — The history of the case, 
the complete relaxation between the spasms, and the late in- 
volvement of the jaw will indicate strychnia-poisoning. 

Tetany. — The history, the paroxysmal character of the 
spasms, the involvement of the hands, and the escape of the 
trunk and jaw will serve to distinguish tetany from tetanus. 

Prognosis. — Unfavorable. Slight involvement of the 
muscles of the trunk, absence of fever, and a slow course are 
favorable features. 

Treatment. — The wound should be rendered aseptic. 
Morphia is indicated for the relief of the pain. Chloral, and 
bromide of potassium (5j every two hours) should be used to 
control the convulsions. When asphyxia is threatened by 
the violence of the spasm, inhalations of chloroform should be 
employed. When the patient is unable to swallow, he must 
be fed through the nose or by the rectum. 



288 ACUTE INFECTIOUS DISEASES. 

DENGUE. 

(Break-bone Fever, Dandy Fever.) 

Definition. — An acute infectious disease, characterized by 
pains in the muscles and joints, a variable rash, and a febrile 
course of two paroxysms. 

Etiology. — Dengue is confined almost entirely to hot cli- 
mates. Although it occurs in epidemics, its contagiousness is 
still a matter of dispute. 

Period of Incubation. — Three to five days. 

Symptoms. — The invasion is usually sudden and is attended 
with lassitude, chilliness, headache, intense pain in the muscles 
and joints, and high fever. The latter rises rapidly and often 
reaches a maximum of 104°— 105° in a few hours. The pulse 
is rapid and full ; the respirations are accelerated; the mind is 
often delirious ; the urine is scanty ; the joints are swollen and 
stiff. In two or three days the temperature falls, and an 
afebrile period follows in which the patient is free from pain, 
but is profoundly prostrated. During the remission a roseo- 
lar or a diffuse erythematous rash generally appears ; this lasts 
two or three days and is followed by slight desquamation. 
Shortly after the subsidence of the rash, the fever and pains 
again return, and persist for two or three days when conva- 
lescence begins. 

Diagnosis. — Acute rheumatism. The prevalence of an 
epidemic, and the distinct remission will usually render the 
diagnosis apparent. 

Prognosis. — Favorable. 

Treatment. — There is no specific remedy. High fever 
should be controlled by the external application of cold or by 
the use of antipyrin. Morphia, salol, antipyrin, or phenacetin 
may be employed to relieve pain. Prostration must be com- 
bated by stimulants, like alcohol, quinine, and strychnia. 

HYDROPHOBIA. 

(Rabies.) 

Definition. — A disease of dogs and kindred animals, com- 
municated to man by direct inoculation, and characterized by 






HYDROPHOBIA. 289 

slight fever, painful spasm of the muscles of the throat, deli- 
rium, paralysis, and coma. 

Etiology. — Rabies invariably results from the bite of a 
rabid animal, generally a dog. In the animal the disease is 
characterized by depression of spirits, loss of appetite, followed 
by excitement, aimless roving, a morbid desire to bite, and 
finally by paralysis and death from exhaustion. The poison is 
contained in the saliva and blood. Pasteur has induced the 
disease by direct inoculation, and has found that the virus is 
attenuated by passing several times through the monkey. 
Bites on the face and on exposed parts are more liable to be 
followed by infection. 

Pathology. — Intense congestion of the spinal cord and of 
the respiratory mucous membrane. 

Period of Incubation. — Six weeks to six months. 

Symptoms. First Stage. — Depression of spirits, restless- 
ness, slight difficulty in swallowing, and pain in the wound or 
cicatrix. In a few days the stage of excitement begins. 

Second Stage. — Clonic convulsions, involving especially the 
muscles of the throat, occurring spontaneously or excited by 
drinking or by the sight of water ; hyperesthesia, delirium, 
moderate fever, and salivation. This stage lasts a few days, 
and is followed by paralysis. 

Third Stage. — The pulse weakens ; the convulsions cease ; 
the patient lies motionless ; the mind becomes clouded ; and 
death results in twelve or twenty-four hours from exhaustion. 

Diagnosis. — Hysteria in persons who have been bitten 
may simulate hydrophobia. Such persons often bark, try to 
bite, and manifest other symptoms which are not noted in hy- 
drophobia. 

Prognosis. — Invariably fatal. 

Treatment. Prophylaxis. — Suspicious bites should be 
thoroughly disinfected and cauterized by the hot iron or caus- 
tic potash, after which the patient should be sent to an institute 
where inoculation may be practised after the method of 
Pasteur. 

The Attack. — Palliative. For the convulsive seizures mor- 
phia may be employed hypodermically, and chloroform by inha- 
lation. The strength may be sustained by rectal alimentation.. 
19 



CONSTITUTIONAL DISEASES. 



RHEUMATIC FEVER. 

(Acute Articular Rheumatism, Inflammatory Rheumatism.) 

Definition. — An acute general disease, characterized by 
irregular fever, acid sweats, inflammation of the joints, and a 
marked tendency to involve the heart. 

Etiology. — Heredity, temperate zone, occupations which 
necessitate exposure to cold and wet, early life (15-40), and 
one attack are predisposing factors. The disease is usually 
precipitated by sudden chilling of the body. 

The exciting cause is still unknown. Some regard it as a 
neurosis ; others believe it to be infectious, and classify it with 
pneumonia, erysipelas, and similar diseases ; while still others 
attribute it to deranged -metabolism. According to the last 
theory, the nitrogenous products, instead of being converted into 
urea, are transformed into lactic acid, uric acid, and other allied 
substances, and these deleterious agents are responsible for the 
symptoms. 

Pathology. — The ligaments and the synovial membrane 
and its fringes are congested and swollen. The synovial sac is 
tilled with a turbid fluid. The cartilages are roughened and 
occasionally ulcerated. Generally the process ends in resolu- 
tion ; sometimes the surrounding tissues become infiltrated 
with inflammatory lymph, and false anchylosis results ; rarely, 
suppuration of the joint follows. Sometimes small subcuta- 
neous fibrous nodules are found near the joints and large ten- 
dons. The blood shows an excess of fibrin and a considerable 
diminution of the red corpuscles. Fibrinous clots are often 
found in the heart and great bloodvessels. 

Secondary inflammations are frequently discovered, such as 
endocarditis, pericarditis, pleurisy, or pneumonia. 
(290) 



RHEUMATIC FEVER. 291 

Symptoms. — The symptoms vary much in their severity. 
The disease usually begins abruptly, or more rarely follows such 
prodromes as malaise, chilliness, and sore throat. The large 
joints, especially the symmetrical ones, are usually affected ; 
they are slightly reddened, swollen, exquisitely painful, and 
tender to the touch. The inflammation shows a marked ten- 
dency not only to spread from joint to joint, but to disappear 
abruptly in one while it attacks another. The joints most 
commonly involved are the knees, elbows, ankles, and wrist ; 
but no joint is exempt. In severe cases the muscles are pain- 
ful, tender, and sometimes rigid. The fever rises rapidly to a 
moderate height (102°-103°), and is indefinite in its duration 
and extremely irregular in its course. Perspiration is often 
copious, has a peculiar sour smell and an acid reaction. The 
urine is scanty, high-colored, and on standing throws down an 
abundant sediment of urates and uric acid. The tongue is 
heavily coated ; the appetite is lost ; and the bowels are con- 
stipated. The face is at first flushed, but as the disease 
advances it becomes decidedly pale from anaemia. 

The duration is indefinite, varying from a few days to 
several weeks. 

Complications. — Endocarditis (in 40 per cent, of all cases); 
pleurisy; pericarditis; pneumonia; hyperpyrexia (106°-109°), 
which is often associated with maniacal delirium; chorea; iritis; 
meningitis; and certain cutaneous phenomena, such as urticaria, 
purpura, erythema nodosum, and subcutaneous fibrous nodules. 

Diagnosis. Septic Arthritis. — This may be recognized by 
its association with some other septic process and by the special 
tendency of the inflammation to end in suppuration, which is a 
very rare termination of rheumatic fever. 

Gonorrhoea! Rheumatism. — This may be recognized by the 
history, by its obstinate character, and by its tendency to in- 
volve, not only large joints, but certain small joints which are 
rarely affected in rheumatic fever, like the sterno-clavicular, 
temporo-maxillary, and sacro-iliac. 

Rheumatoid Arthritis. — This begins in the small joints, 
attacks one after another, leads to permanent deformity, is not 
associated with fever and sweats, and shows no tendency to 
involve the heart. 



292 CONSTITUTIONAL DISEASES. 

Gout. — This occurs later in life, usually involves the great 
toe, and lacks high fever, acid sweats, aud the tendency to 
heart complications. 

Prognosis. — Guarded. Most cases end in recovery ; some 
in chronic rheumatism ; a very small number die of 
exhaustion, or some complication, such as hyperpyrexia. It 
is very prone to relapse and to recur. The most frequent 
complication is endocarditis ; this may never give rise to 
trouble, but frequently it leads to slow thickening or retrac- 
tion of the valves and to all the phenomena of chronic heart 
disease. 

Treatment. — Absolute rest in a room well-ventilated but 
free from draft ; the patient should lie between blankets. 
The diet should consist mainly of milk and light broths ; meat 
should be interdicted. The free use of lemonade or mineral 
waters should be encouraged. Opium, phenacetin, or antipy- 
rin may be required to relieve the pain. 

Two remedies have considerable power in controlling the 
disease : salicyl compounds, and alkalies, like the salts of potas- 
sium ; these remedies may be given separately or in combina- 
tion. The salicylates relieve the pain, but do not prevent re- 
lapses or cardiac complications ; the alkalies apparently lessen 
the tendency to endocarditis. 

Salicylic acid (gr. x in capsules) or salicylate of sodium (gr. 
x-xx) may be given every two hours. Large doses may excite 
nausea and ringing in the ears. 

I£ Sodii salicylat., ^ij ; 

Tinct. cardamom, comp., giv ; 
Glycerin., ^ij ; 
Aquae q. s. ad f^iv.— M. 
Sig. — A tablespoonful every two hours. 

The oil of gaultheria (wix every two hours) is another sali- 
cyl compound of decided value. If alkalies are employed, 
half a drachm of bicarbonate of potassium may be administered 
every two hours until the urine becomes distinctly alkaline. 
It is a good plan to combine alkalies with salicylates, thus : — 



EHEUMATIC FEVER. 293 

T$l Sodii salicylate, gij ; 
Potass, bicarb., 3iij ; 
Glyce rinse, 

Tinct. cardamom, comp., aa 13 ss ; 
Aquae q. s. ad f^v. — M. 
Sig. — A tablespoonful every two hours. 

When there is much anaemia Basham's mixture (3j-^ss) 
may be given with the salicylate, or the following combina- 
tion may be employed : — 

J$l Acid, salicylic, £ss ; 
Ferri pyrophosphate 3j ; 
Sodii phospbatis, ^x ; 
Aquse, fjvj.— M. (Peabody.) 
Sig. — Tablespoonful every two hours until relieved. 

Local Treatment — The joints may be painted with iodine- 
and wrapped in cotton- wool. In severe cases small blisters 
are of great utility. Chloroform liniment, aconite liniment, 
lead-water and laudanum are also efficient remedies. The 
salicyl preparations, when applied locally, often relieve the 
pain better than any other remedy. The following mixture 
may be employed : — 

^ ^Jther., 
Alcohol. , 

Ol. gaultherise, aa Jj ; 
Lin. saponis q. s. ad Oj.— M. 

Sig. — Apply locally. 

Or— 

I£ 01. gaultherise, 

01. olivse, 

Lin. saponis, 

Tinct. aconit., 

Tinct. opii, aa sjij. — M. 
Ft. liniment. 
Sig. — Apply locally. 

Sometimes ichthyol proves serviceable. 

^ Ichthyol, 3ij ; 

Ext. belladonna?, 3j ; 
Yaselin., ^ij.— M. 
Sig. — Apply locally. 

Hyperpyrexia. — This should be treated promptly by the 
cold pack or the cold bath. 



294 



CONSTITUTIONAL DISEASES. 



Endocarditis. — This usually causes no subjective disturbance 
and the general treatment need not be modified. When the 
pulse is rapid and irregular, and the patient complains of 
precordial distress, a blister may be applied and digitalis may 
be given internally. Absorbents like the iodide of potassium 
are useless. Convalescence should be protracted so as to allow 
time for perfect compensation. 

Convalescence. — Such tonics as iron, quinine, and strychnia 
are useful during this period. 

CHRONIC RHEUMATISM. 

Etiology. — It usually begins as a chronic affection. He- 
redity, advanced years, and habitual exposure to cold and wet 
are the predisposing factors. It rarely results from an acute 
attack. 

Pathology. — The fibrous structures around the joint are 
greatly thickened, so that in long-standing cases the movements 
are restricted ; the neighboring muscles are wasted from disuse; 
and the nerves often reveal evidences of neuritis. 

Symptoms. — Pain, stiffness, deformity, and creaking of the 
joints are the usual phenomena. Several joints are commonly 
affected, and the disease shows no predilection for any par- 
ticular joint. The symptoms grow worse on the approach of 
stormy weather, and at such times exacerbations are liable to 
occur, in which the' joints become swollen and tender. The 
duration is indefinite. 

Complications. — Arterial degeneration and chronic endo- 
carditis. 

Prognosis. — Generally unfavorable. Much relief may fol- 
low persistent and judicious treatment, but perfect cure is 
rarely attainable. 

Treatment. — Especial attention should be given to the 
hygiene, particularly as regards diet, bathing, clothing, exer- 
cise, and occupation. A change of residence to a dry, warm, 
and equable climate may effect a cure. The tone of the sys- 
tem is often reduced ; hence, tonics like iron, quinine, strychnia, 
and arsenic may be of considerable value. The special reme- 
dies are iodide of potassium, guaiac, sulphur, salicylic acid, 






CHRONIC RHEUMATISM. 295 

and alkalies like the salts of potassium and lithium. Mineral 
waters are sometimes useful. 

I£. Liq. potass, arsenitis, f 31J ; 
Potass, iodid., gij ; 
Syr. simp., fgiij.— M. (DaCosta.) 
Sig. — A teaspoonful three times a day in water after meals. 



OTHER MANIFESTATIONS OF RHEUMATISM. 

Muscular Rheumatism {myalgia, myodynia).- — An affection 
of the voluntary muscles, characterized by pain, tenderness, and 
rigidity. 

Types. — Different names have been applied according to 
the location, namely : Torticollis, or wry-neck, when it in- 
volves the sterno-cleido-mastoid muscles ; lumbago, when it- 
involves the lumbar muscles; pleurodynia, when it involves 
the intercostals ; and cephalodynia, when it involves the oc- 
cipito-frontalis. 

Etiology — -The gouty or rheumatic diathesis is a predis- 
posing cause. Exposure to cold and wet or muscular strain 
usually excites it. 

Symptoms. — Pain is the chief symptom ; it is made worse 
by use of the muscles, and is associated with tenderness which 
is especially marked at the tendinous origins and insertions of 
the muscles. Sometimes the muscles are contracted and rigid ; 
this is particularly the case in torticollis, or wry-neck. 

Torticollis. — The head is fixed and inclined to one side ; 
eveiy effort to turn it is attended with sharp pain. 

Lumbago. — There is a dull, aching pain across the loins. 
Turning the body or rising from the sitting posture causes an 
exacerbation, which is sometimes so severe that the patient 
cries out. Care must be taken to distinguish it from renal cal- 
culus, Pott's disease, aneurism, perinephritis, and uterine or 
ovarian disease. 

Pleurodynia. — The pain is felt in the side, and is increased by 
deep breathing, coughing, or twisting the body ; the respirations 
are restricted on the affected side. There is diffuse tenderness 
to the touch. The absence of fever and of physical signs will 
serve to distinguish it from pleurisy. 



296 CONSTITUTIONAL DISEASES. 

The absence of tender spots where the nerves make their 
exit from the muscular coverings, the fact that the pain does 
not follow closely the distribution of the nerves, and that the 
pain is increased by movement, will serve to distinguish pleuro- 
dynia from intercostal neuralgia. 

Cephalodynia. — This is characterized by a superficial head 
pain which is increased by moving the scalp and which is 
associated with tenderness on pressure. 

Prognosis. — Favorable under judicious and persistent 
treatment. 

Treatment. — The affected muscles should be put at rest. 
In pleurodynia this is best accomplished by strapping the 
affected side as for fracture of the ribs. In lumbago a large 
piece of adhesive plaster may be applied from the floating ribs 
to the iliac crests. In mild cases the thorough application of 
liniments containing chloroform, aconite, belladonna, and lauda- 
num will be all that is required. In other cases prompt relief 
often follows the injection of morphia (gr. J) with atropia (gr. 
lis); directly into the muscle. The continued current is some- 
times useful. The introduction of needles, three or four inches 
long, deeply into the muscles (acupuncture) occasionally gives 
brilliant results. 

Internally, in acute cases, chloride of ammonium (gr. x four 
times daily) may prove efficient. In chronic cases, iodide of 
potassium, guaiac, colchicum, and the salts of lithium are the 
remedies usually employed. Gelsemium pushed to its physio- 
logical limit has been successful when other remedies have 
failed. 

Neural Manifestation. — Rheumatism appears to be a fre- 
quent cause of neuritis. 

Rheumatic Affections of Mucous Membranes. — It must be 
borne in mind that pharyngitis, tonsillitis, laryngitis, and 
bronchitis are sometimes dependent upon a rheumatic diathesis. 

Rheumatic Affections of Serous Membranes.— -Endocar- 
ditis, pericarditis, pleuritis, iritis, and peritonitis may be excited 
by rheumatism. 

Cutaneous Manifestations.— Purpura, urticaria, and ery- 
thema nodosum are sometimes associated with rheumatism. 



gout. 297 

GOUT. 

(Podagra.) 

Definition. — A general disease, characterized by varied 
constitutional disturbances, the presence of uric acid in the 
blood, the deposition of urate of soda in the fibrous structures 
of the joints, and recurrent attacks of acute arthritis. 

Etiology. — Middle and advanced life, male sex, heredity, 
a rich diet and the indulgence in liquors (especially malt 
liquors and strong wines), want of exercise, and working in 
lead are general predisposing factors. 

Pathology. — The blood contains uric acid, and the fibrous 
structures of the joint are the seat of a deposit of urate of soda. 
It is probable that from defective nerve-power the tissues 
generally are unable to perfect the metabolism of nitrogenous 
products into urea, and that uric acid and allied substances are 
thus formed. According to Ebstein, the uric acid excites a 
necrosis of the cartilages, whereupon the urates are crystallized 
out aud deposited. 

The cartilages lose their pearly appearance and become 
lustreless and infiltrated with salts ; similar opacities appear in 
the synovial membrane; later rounded masses of urate of soda 
(tophi), varying in size from a pea to a marble, accumulate in 
the tissues surrounding the joint and may ulcerate through the 
skin and be discharged. The fibrous structures become brit- 
tle and undergo destructive changes. The joint becomes 
irregularly enlarged, stiff, and finally anchylosed. The meta- 
tarso-phalangeal joint of the great toe, especially the right one, 
is first affected, but soon other small joints are involved. 
Gouty deposits are sometimes found along the tendons, beneath 
the peritoneum, in the perichondrium of the ear, and in the 
tarsal cartilages. 

The kidneys are generally the seat of a chronic interstitial 
inflammation, and section frequently reveals a deposit of 
urates at the apices of the pyramids (gouty kidney). The 
arteries are sclerosed and the left side of the heart is hypertro- 
phied. 

Symptoms. Acute Gout. — Such prodromes as restlessness, 
insomnia, moroseness, and irritability of temper may precede the 



298 CONSTITUTIONAL DISEASES. 

attack. The arthritic phenomena usually appear suddenly in the 
early morning hours and are characterized by pain and swell- 
ing in the ball of the great toe. The affected joint is exqui- 
sitely painful and tender, so that the slightest pressure cannot 
be borne ; it is of a reddish -purple color ; its surface is glazed; 
and the neighboring veins are full and distinct. 

The constitutional symptoms are restlessness, chilliness, 
moderate fever, perspiration, constipation, and scanty high- 
colored urine, which contains, during the paroxysm, less urates 
than in health. Towards daylight the symptoms abate and 
the patient falls to sleep. During the day he is comparatively 
comfortable, but there are severe exacerbations for several 
successive nights. At first the attacks may be a year apart, 
but as they multiply the interval grows less, until finally the 
patient is seldom entirely free from suffering. 

Retrocedent Gout. — This term is applied to a condition in 
which the arthritic phenomena suddenly subside and grave 
gastric, cardiac, or cerebral symptoms follow. 

Chronic Gout. — The joints are affected one by one, and 
become stiff, irregularly enlarged, and deformed. Chalk- 
stones, or tophi, sometimes ulcerate their way through the 
skin and are discharged. Similar deposits are frequently 
found along the tendons and in the helix of the ear. The 
constitutional symptoms vary much in severity and in char- 
acter. 

Nervous Phenomena. — Vertigo, headache, insomnia, irrita- 
bility of temper, and hypochondriasis. 

Gastro- intestinal Phenomena. — Perverted appetite, dyspepsia, 
constipation, and a tendency to hemorrhoids. 

Urinary Phenomena. — The urine is at first scanty, high- 
colored, and throAVS down an abundant brick-dust sediment ; 
but ultimately interstitial nephritis develops and the urine 
becomes pale, copious, of a low specific gravity, and contains 
albumin and hyaline casts. Glycosuria is also frequently ob- 
served. 

Circulatory Phenomena. — High arterial tension, accentua- 
tion of the aortic second sound, and later, arterio-sclerosis and 
hypertrophy of the left ventricle. 



gout. 299 

Complications and Sequel je. — Interstitial nephritis, 
arterio-sclerosis, hypertrophy of the heart, apoplexy, chronic 
bronchitis, and cutaneous eruptions, especially eczema. 

Diagnosis. — The symptoms of acute gout are so charac- 
teristic that an error in diagnosis is scarcely possible. 

Chronic gout may be mistaken for chronic rheumatism ; 
but the former attacks especially the small joints ; it begins 
in the great toe ; the blood contains an excess of uric acid ; 
and the symptoms are not so much influenced by atmospheric 
changes as by diet. 

Prognosis. — As regards the acute form, the prognosis is 
good. The liability to arterial degeneration and to nephritis, 
and the difficulty in securing cooperation in carrying out the 
treatment render the prognosis of chronic gout rather unfavor- 
able. 

Treatment. The Acute Attack. — The best remedy is col- 
chicum ; ten to twenty drops of the wine well diluted should 
be given every two hours, and stopped as soon as the symptoms 
subside. Alkalies are valuable adjuncts, and the salts of potas- 
sium or of lithium may be given with the colchicum. Quinine 
is also useful ; it may be given in doses of five grains thrice 
daily. The free use of water should be encouraged, and a 
water containing lithium, like the Buffalo lithia water, may 
be recommended. Constipation should be relieved by a full 
dose of blue mass or a saline draught. Opium may be required 
for the relief of the pain. The affected part should be elevated 
and wrapped in cotton-wool, or covered with warm fomenta- 
tions or with cloths soaked in lead- water and laudanum. The 
diet should be light and non-stimulating. 

Chronic Gout. — The diet must be restricted and carefully 
arranged for each patient. Light meats, fish, eggs, and oysters 
may be used in moderation ; sweet fruits should be avoided ; 
starches and sugars must be limited ; and the use of liquors 
interdicted. The condition of the tongue, stomach, and urine 
will indicate the value of this or that dietary. Mineral waters 
are often serviceable, and Carlsbad, Vichy, and Buffalo lithia 
are among the best. Their utility will be enhanced by the addi- 
tion of a teaspoonful of some effervescing salt of lithium to 
each potation. A free secretion of the skin should be encour- 



300 CONSTITUTIONAL DISEASES. 

aged by frequent bathing followed by friction. The bowels 
should be kept regular by salines or by the occasional use of 
a mercurial laxative. Graduated exercise holds a prominent 
place in the therapy of gout. When the digestive powers are 
particularly weak, mineral acids with strychnia will prove 
useful. General tonics are sometimes indicated. The special 
remedies are colchicum, lithium, and iodide of potassium. 

]$_ Vini sera, colchici, fgss ; 
Potass, iodidi, ^ij ; 
Liq. potass., f^iss ; 

Tr. zingiberis, f^ij.— M. (Hodgson.) 
Sig. — A teaspoonful twice daily in warm water. 

Or small doses of colchicum may be given with — 

fy Litlrii benzoat., ^ij ; 

Aq. einnamora., fgijss. — M. (Jaccoud.) 
Sig. — A teaspoonful in a wineglass of water every four hours. 

The arthritic condition is best treated by careful massage 
and warm sulphur baths. 



RHEUMATOID ARTHRITIS. 

(Arthritis Deformans, Rheumatic Gout.) 

Definition. — A chronic affection of the joints characterized 
by destruction of the cartilages, new osseous formations, im- 
mobility, and deformity. 

Etiology. — Heredity ; early adult life ; female sex ; con- 
tinued emotional disturbances, as anxiety and grief; enfeeble- 
ment of health from bad hygienic environment, prolonged 
lactation, and from frequent pregnancies, are the predisposing 
causes. 

Pathology. — Many look upon rheumatoid arthritis as a 
disease which is related both to gout and rheumatism. Others 
regard it as a neurosis and allied to the arthropathies which 
are met with in chronic affections of the spinal cord. 

The cells of the cartilages and of the synovial membrane 
proliferate and lead to villous or nodular outgrowths. The 
central portions of the cartilages ultimately wear away and 
leave the bones exposed. The heads of the bones become 



RHEUMATOID ARTHRITIS. 301 

smooth aud hard like ivory, and thickened from exostoses. 
The synovial membrane and periarticular tissues are likewise 
thickened and sometimes infiltrated with bony products. The 
surrounding muscles are generally atrophied. All joints are 
liable to be affected. 

Symptoms. — It may be either acute or chronic, the latter 
being the more common form. In the acute form several 
joints are simultaneously involved ; they become swollen, pain- 
ful, and slightly reddened. There is moderate fever. The 
symptoms soon subside, to reappear, however, at frequent 
intervals. 

In the chronic jorm y the hands, particularly the metacarpo- 
phalangeal joints, are usually first affected ; then the wrists, 
knees, toes, jaws, and spine. Symmetrical joints are usually 
attacked. The symptoms are : Swelling, pain, immobility, and ' 
deformity ; the joints are stiff and creak when moved ; later 
complete anchylosis develops ; the muscles waste and con- 
tractures increase the deformity. In advanced cases the fingers 
are bent backward, often locked, and turned toward the ulnar 
side ; the thighs are drawn up ; the legs are adducted and 
flexed. The patient may be a helpless invalid for many years. 

Diagnosis. Gout. — The circumstances under which gout 
develops ; the history of an acute attack in the great toe ; the 
presence of uric acid in the blood ; the presence of urate of 
soda in the joints and in the cartilages of the ear will serve to 
distinguish the two diseases. 

Chronic Rheumatism. — Unlike chronic rheumatism, rheu- 
matoid arthritis begins in the small joints, passes from joint 
to joint, and leaves permanent deformity. 

Prognosis. — Unfavorable. Sometimes the disease is local 
and remains in one joint (mono-articular form). Generally 
several joints are affected, and while judicious and persistent 
treatment may retard the progress of the disease, a cure is 
rarely attainable. 

Treatment. — Good hygiene. Tonics like iron, arsenic, 
phosphorus, and cod-liver oil are useful. The most good is 
to be expected from local treatment, which consists of massage, 
electricity, steam baths, and inunctions of preparations con- 
taining iodine or mercury. 



302 CONSTITUTIONAL DISEASES. 

RICKETS. 

(Rachitis.) 

Definition. — A constitutional disease of early childhood, 
characterized chiefly by defective nutrition of the osseous 
structures. 

Etiology.- — Rickets is rarely congenital ; it usually de- 
velops between the first and second years. Poverty, artificial 
feeding, and bad hygienic conditions are the predisposing 
causes. 

Pathology. — The most marked changes are observed in 
the long bones and ribs. The cartilaginous lamina between 
the epiphysis and the shaft are considerably thickened, and 
are spongy and irregular in outline ; microscopic examination 
reveals an excessive proliferation of the cartilage-cells with 
scanty calcification. The periosteum is thickened and highly 
vascular, and when stripped off soft porous bone is exposed. 
The bones are soft, being extremely deficient in lime-salts ; 
when ossification finally results the bones become heavy, large, 
and irregular in outline ; these changes correspond to the clinical 
phenomena — bow-legs, knock-knees, spinal curvature, pigeon- 
breast, and square cranium. 

The liver and spleen are often considerably enlarged. 

Symptoms. — The early symptoms are : Restlessness and 
slight fever at night ; free perspiration about the head ; dif- 
fuse soreness and tenderness of the body ; pallor ; slight diar- 
rhoea ; enlargement of the liver and spleen ; delayed dentition 
and the eruption of badly-formed teeth. 

Skeletal Phenomena. — The head is large and more or less 
square in outline ; careful palpation may detect soft areas. 
The sides of the thorax are flattened ; the sternum is promi- 
nent ; nodules can be felt at the sternal ends of the ribs — 
" rachitic rosary" ; there may be a distinct transverse groove at 
the level of the ensiform cartilage; the spinal column is fre- 
quently curved antero-posteriorly or laterally ; the long bones 
are curved and prominent at their extremities. 

Complications. — Green-stick fractures, convulsions, laryn- 
gismus stridulus, paresis of the extremities, and acute pulmo- 



LITHJEMIA. 303 

nary diseases. In women the rachitic pelvis may seriously 
complicate labor. 

Prognosis. — Rachitis does not kill directly, but death is not 
uncommon from intercurrent disease. Under good hygienic 
conditions recovery, with more or less deformity, generally 
follows. 

Tkeatment. — The general nutrition must be improved by 
placing the child under the best hygienic conditions. Eggs, 
pure milk, prepared food, and broths should be recommended. 
Cod-liver oil is a valuable nutrient tonic. Iron is indicated 
for the ansemia. The lack of calcareous material in the bones 
should be supplied by the administration of phosphorus and 
lime- salts. 

]£ Syr. ferri iodid. , f^iss ; 
Mist. ol. morrhua? et 

Lactophos. calcis, q. s. ad f^iij. — M. (Stake,.) 
Sig. — From one-half to a teaspoonful three times a day. 

IATUJEMIA. 

(Lithic-acid Diathesis, Uric-acid Diathesis, Latent Gout.) 

Definition. — A constitutional disease dependent upon mal- 
assimilation of nitrogenous products and the formation of uric 
acid and allied substances instead of urea, and characterized 
by an excess of uric acid in the urine, and varied digestive, 
circulatory, and nervous phenomena. 

Etiology. — Gout with an acute arthritic expression is un- 
common in America, but latent gout, or lithsemia, is extremely 
common. Impaired digestion, insufficient exercise, mental 
strain, and over-eating are the usual causes. 

Symptoms. Gastrointestinal Phenomena. — The tongue is 
generally coated and the breath heavy ; the appetite is variable, 
sometimes it is lost, at others it is inordinate ; acid eructations, 
" heartburn," and flatulence are frequent gastric symptoms ; 
the bowels are usually constipated. 

Urinary Phenomena. — The urine is scanty, high-colored, of 
high specific gravity (1025 - 1035), and on standing throws 
down an abundant brick-dust sediment. The solids render 
the urine irritating, so that dull aching in the loins and burn- 



304 CONSTITUTIONAL DISEASES. 

ing in the penis after micturition are common symptoms. A 
trace of sugar is sometimes detected on chemical examination. 
The urine often stains the clothes red. 

Circulatory Phenomena. — High arterial tension, accentua- 
tion of the aortic second sound, and a tendency to atheroma. 

Nervous Phenomena. — Headache, vertigo, disturbed sleep, 
tinnitus aurium, depression of spirits, failure of memory, loss 
of energy, irritability, and neuralgic pain in various parts of 
the body. 

Sequelae. — Arterial degeneration, interstitial nephritis, 
hepatic cirrhosis, gastritis, renal or vesical calculi. 

Diagnosis. — This rests on the general symptoms and the 
analysis of the urine. 

Prognosis. — Favorable under prolonged and judicious 
treatment. 

Treatment. — Special attention must be given to the diet. 
It is a mistake to cut off all nitrogenous foods, for often the chief 
difficulty is in digesting the starches and sugars. Light meats, 
green vegetables, eggs, and oysters- are admissible. The use 
of fats, heavy meats, sweets, starches, and alcoholic beverages 
must be restricted. Xext to diet, regular exercise is the most 
important therapeutic measure ; the patient must eat less or 
burn up more material, and the chief stimulant of tissue-metab- 
olism is exercise. A change of scene may effect brilliant results. 
Frequent bathing with salt water followed by friction is a 
valuable adjunct. AVhen the gastric digestion is weak, mineral 
acids, strychnia, and pepsin are useful remedies. The salts of 
potassium aud lithium are solvents of uric acid ; citrate of 
lithium (gr. xx), benzoate of lithium (gr. v), or citrate of potas- 
sium (gr. xx), may be given, well diluted, two hours after 
meals. Mineral-waters containing these salts may be recom- 
mended. The bowels should be kept regular by some simple 
laxative. 

DIABETES. 

(Diabetes Mellitus.) 

Definition. — A nutritional disease, characterized by the 
persistent presence of sugar in the urine, polyuria, and loss of 
flesh and strength. 



DIABETES. 305 

Etiology. — Heredity, adult life, male sex, the Hebrew 
race, prolonged mental anxiety, and dietetic errors are pre- 
disposing causes. It rarely follows injury of the brain or cord. 

Pathology. — The lesions found, after death have been so 
varied that the condition which is really responsible for diabetes 
is still undetermined. Puncture of the floor of the fourth 
ventricle will produce glycosuria, but the cases are rare in 
which lesions of this region have been found after death. In 
a notable number of cases the pancreas is the seat of cirrhosis 
and of fatty degeneration, but the relation of this condition to 
diabetes is still unknown. The liver is frequently enlarged and 
the seat of degeneration changes. The kidneys are enlarged 
and often reveal evidences of parenchymatous inflammation. 

According to one view, diabetes has its origin in the sympa- 
thetic nervous system, and results from a vaso-motor dilatation 
of the hepatic vessels causing a disturbance of the glycogenic 
function of the liver and the discharge of glucose in the urine. 

According to another theory, diabetes results from a func- 
tional or organic disease of those organs, particularly the pan- 
creas and liver, which are engaged in the assimilation of 
starches and sugars. 

Symptoms. Urinary Phenomena. — The urine is increased 
in quantity, the amount varying from three or four pints to as 
many gallons ; its color is pale ; its specific gravity ranges 
from 1015 to 1050 ; it has a sweetish taste and an aromatic 
odor. In summer it attracts flies and rapidly ferments. It 
may leave a whitish residue on the clothes. The percentage of 
glucose varies from a half per cent, to ten per cent. ; the total * 
amount excreted in twenty-four hours varies from a few ounces 
to a pound or more. 

General Phenomena. — There is loss of flesh and strength ; 
the temperature is normal or subnormal ; the appetite is often 
inordinate, and the thirst unquenchable; the tongue is 
generally fissured and beefy-red ; the bowels are usually con- 
stipated. 

Cutaneous Phenomena. — The skin is harsh and dry, and fre- 
quently the seat of intense itching. Pruritus is especially ob- 
served at the genitalia, and this may be the first subjective 
symptom. 
20 



306 CONSTITUTIONAL DISEASES. 

Nervous Phenomena. — Headache, depression of spirits, 
diminished or lost patellar reflexes, impaired sexual power, 
dimness of vision, and neuralgia. 

The duration varies from a few weeks in the acute form to 
many years in the chronic form. 

Complications. — Pulmonary tuberculosis, pneumonia, 
gangrene of the lung ; defective vision from soft cataract, 
retinitis or atrophy of the optic nerve ; cutaneous lesions, as 
boils, eczema, carbuncles, and gangrene ; nephritis ; and 
diabetic coma, or acetonemia. 

This last condition is characterized by epigastric pain, dys- 
pnoea, a sweetish odor of the breath, headache, delirium, stupor, 
and coma ; it probably results from the presence of diacetic and 
oxybutyric acids in the blood. 

Diagnosis. — Care must be taken to distinguish simple gly- 
cosuria from diabetes. The former is recognized by being 
transient, and unassociated with the constitutional symptoms of 
diabetes. 

Pruritus and apparently causeless loss of flesh and strength 
should lead to a suspicion of diabetes. 

Prognosis. — The younger the patient, the stronger the 
hereditary tendency, the larger the amount of sugar excreted ; 
the less the glycosuria can be controlled by diet alone, the 
graver the prognosis. On the other hand, when it occurs after 
middle life in association with a gouty diathesis, and the gly- 
cosuria is not pronounced, the prognosis for a long duration is 
comparatively favorable. Absolute cure is rarely attainable. 

Treatment. Dietetic Treatment. — Sugars and starches 
must be restricted. Since the patient's appetite is often inordi- 
nate, it is necessary to regulate the quantity and character of 
those foods which are recognized as admissible. The following 
foods may be included in the dietary : — 

Animal Foods. — Meats of various kinds (except liver), 
game, light broths and soups, fish, and eggs. 

Vegetables. — Celery, lettuce, cauliflower, tomatoes, mush- 
rooms, string-beans, young onions, olives, water-cress, and 
spinach. 

Beverages. — Buttermilk, skim milk, sour wines (Rhine 
wines), carbonated waters, and coffee and tea without sugar. 



DIABETES. 307 

Relishes. — Nuts of all kinds (except chestnuts), cream cheese, 
and pickles. 

Bread. — Bread made of gluten, bran flour, or almond flour. 
It should be borne in mind that all the gluten flours are rich 
in starch. 

Fruits. — Cranberries, sour cherries, limes, lemons, and red 
currants. 

Substitutes for Sugar. — Saccharin and glycerin. 

The following foods should be avoided : Liver, oysters, 
wheat bread, biscuits, pastry, potatoes, beets, carrots, peas, 
turnips, parsnips, sweet fruits, rice, barley, tapioca, corn-starch, 
corn-meal, chocolate, cocoa, syrups, preserves, and most liquors. 

Hygienic Treatment. — Graduated exercise ; frequent bathing 
with salt water followed by friction ; the use of flannel 
underclothing; plenty of rest and sleep; and, if possible, a. 
change of scene. 

Medicinal Treatment. — Tonics like iron, arsenic, strychnia, 
and cod-liver oil are often indicated. The special remedies 
are opium and its alkaloids — morphia and cocleia — bromide of 
arsenic, ergot, antipyrin, salicylate of sodium, and alkalies. 
Opium is generally the most useful drug ; it should be given 
in small doses gradually increased until the patient takes five 
or six grains daily. Codeia (gr. ^ increased to gr. vj a day) has 
been thought preferable to either opium or morphia, but accor- 
ding to the clinical experiments of Bruce and Osier, morphia 
is much more reliable. The latter may be employed in doses 
of one-fourth of a grain three or four times daily. The bro- 
mide of arsenic is sometimes of decided value ; it may be given 
in the following solution : — - 

J$l Liq. arsenici brom. (Clemens), f^j. 
Sig. — Two to five drops well diluted after meals. 

In gouty patients a course of Carlsbad water with salicylate 
of sodium (gr. iij-v thrice daily) and antipyrin (gr. v-x thrice 
daily) may be recommended, or : — 

T$l Sodii salicylat., ^iij ; 

Liq. potass, arseuitis, f^j ; 
Glycerinse, f^j ; 

Aq. cinnamorai, ad f^iij.— M. (J. G. Wilson.) 
Sig. — A teaspoonful to a dessertspoonful thrice daily 



308 tXMTSTITUTIDNAIi DISEASES. 

Diabetic coma is always fatal, but the intravenous injection 
of a copious solution (3 per cent.) of bicarbonate of sodium 
may give a few hours'" respite, in which consciousness returns. 

DIABETES INSIPIDUS. 

Definition. — A chronic condition characterized by the 
excretion of large quantities of pale, limpid urine of low specific 
gravity and free from albumin aud sugar. 

Etiology. — Diabetes insipidus must be distinguished from 
the simple polyuria observed in chronic renal disease, in cer- 
tain diseases of the brain, and in some cases of hysteria. 

Diabetes insipidus sometimes develops without obvious 
cause. It is more common in the young, and more males are 
attacked than females. It is occasionally hereditary. It has 
been induced by injury and by certain diseases of the brain. 
Profound emotional disturbance has excited it. Syphilis, 
overwork, and the free use of cold water when the body has 
been overheated, are reputed causes. 

Pathology. — Little is known of the pathology. The 
kidneys are frequently enlarged and congested, and the ureters 
dilated. 

The theory which is generally accepted as accounting for 
the polyuria, is that it is due to a vaso-motor paresis of the 
renal vessels, which permits a free transudation of liquid. 

Symptoms. — The disease may begin insidiously or abruptly ; 
the latter is the rule. The urine: The quantity is increased, 
often as much as eight or ten quarts being excreted in the 
twenty-four hours ; it is pale, and resembles water ; it has a 
specific gravity of 1002-1005. The total amount of solids is 
not diminished. Albumin and sugar are generally absent, 
though there may be a trace of the latter. 

General Symptoms. — Insatiable thirst: good appetite; a 
harsh, dry skin : a dry tongue : constipation ; mental apathy ; 
and emaciation. 

Duration. — When unassociated with organic disease the 
duration may be indefinite. 

Complications. — These are much less common than in 
diabetes mellitus. Cataract, pruritus, boils, and tuberculosis 
have been observed. 



DIABETES INSIPIDUS. 309 

Diagnosis. Diabetes Mellitus. — The low specific gravity 
of the urine and the absence of sugar will serve to distinguish 
diabetes insipidus from diabetes mellitus. 

Interstitial Nephritis. — The presence of albumin, hyaline 
casts, high arterial tension, accentuation of the aortic second 
sound, and the cardiac hypertrophy will indicate nephritis. 

Symptomatic Polyuria. — The history and a careful physical 
examination will usually prevent an error in diagnosis. 

Prognosis. — Usually unfavorable. A permanent cure is 
sometimes effected. Death results from exhaustion, or more 
frequently, from some intercurrent disease. 

Treatment. — The hygienic treatment suggested for diabetes 
mellitus is applicable in this disease. No benefit is derived 
from cutting off the amount of water drunk. Lemonade and 
other acid drinks may serve to lessen the amount of liquid 
consumed. 

The remedies recommended are ergot, strychnia, opium, 
valerian, and nitric acid. Galvanism— one pole applied to 
the neck and the other to the loins — has given good results. 
When syphilis is suspected, the mercurials and iodides may be 
administered freely with good hopes of a successful issue. 

fy Pulv. opii, gr. iv ; 

Acid, gallici, gij.— M. (H. C. Wood.) 
Ft. in chart. No. xii. 
Sig. — One, three or four times daily. 



DISEASES 



NERVOUS SYSTEM 



DISTURBANCES OF MOTION. 

These consist, for the most part, of loss of power, or para- 
lysis, and manifestation of motor excitation, such as convul- 
sions, choreiform movements, and tremors. 

Paralysis. 

The paralysis may be irregularly distributed, or it may in- 
volve a single member, when it is termed monoplegia ; a lateral 
half of the body, when it is termed hemiplegia ; or the body 
from the waist down, when it is termed paraplegia. 

Irregular paralysis may result from : — 

1. Disseminated Jesions in the motor areas of the brain, 
which are commonly syphilitic. 

2. Lesions in the basal ganglia — pons, crura cerebri, medulla, 
when it is often associated with headache, vomiting, vertigo, 
and optic neuritis. 

3. Acute poliomyelitis. This develops abruptly ; it occurs 
in young children ; and it is followed by rapid improvement in 
some muscles and permanent atrophy and paralysis in others. 

4. Chronic poliomyelitis. This develops in middle life ; 
begins in the small muscles of the hand ; is associated with 
atrophy ; and progresses very slowly. 

5. Idiopathic muscular atrophy. This commonly develops 
during adolescence ; involves the muscles of the arm, shoulder, 

(310) 



DISTURBANCES OF MOTION. 311 

buttocks, and thigh ; is associated with atrophy; and can be 
frequently traced to heredity. 

6. Pseudo-muscular hypertrophy. This develops in child- 
ren ; is associated with enlargement of the affected muscles ; 
and can be frequently traced to heredity. 

7. Multiple neuritis. This is recognized by the history, 
pain, disturbances of sensation, and tenderness over the nerve- 
trunks. 

8. Syringo-myelia. This is rare ; develops during ado- 
lescence ; and is recognized by pains, atrophy of the affected 
muscles, a spastic condition of the paralyzed members, and a 
loss of thermic and painful sensations, while tactile sensation 
is retained. *- 

Monoplegia may result from : — 

1. A focal lesion in the cortical area of the brain. This- 
may be recognized by the history, the absence of wasting, of 
sensory disturbances, and of the reactions of degeneration. 

2. A lesion of the peripheral nerve, from traumatism, neu- 
ritis, or the pressure of a tumor. Brachial monoplegia fre- 
quently results from the pressure of the head on the arm 
during sleep. Monoplegia of peripheral origin is recognized 
by the history, the wasting, the sensory disturbances, and the 
presence of reactions of degeneration. 

3. Hysteria. This may be recognized by the history, sex, 
and temperament ; the paroxysmal character of the paralysis ; 
the disturbances of sensation ; and contractures without atrophy 
or electrical disturbances. 

Facial monoplegia may result from a small lesion in the 
facial centre of the cortex or in the medulla ; or from involve- 
ment of the nerve in the canal of the temporal bone; or after 
its exit from the stylo-mastoid foramen. 

Facial diplegia (double facial paralysis) generally results 
from a lesion at the base of the brain. 

Hemiplegia may result from : — 

1 . A diffuse lesion of the motor cortex. The paralysis is 
on the opposite side of the body and is unassociated with 
anaesthesia. 

2. A lesion of the internal capsule or the adjacent ganglia 
(corpus striatum and optic thalamus). This is the most 



312 DISEASES OF THE NERVOUS SYSTEM. 

common seat of hemorrhage ; the paralysis is on the opposite 
side of the body and is unassociated with anaesthesia. 

3. A lesion of the crus cerebri. This frequently produces 
hemiplegia and hemianesthesia on the opposite side, and par- 
alysis of the oculo-motor nerve on the side of the lesion, indi- 
cated by dilated pupil, strabismus, and ptosis. 

4. A lesion of the pons. This frequently produces hemi- 
plegia and hemianesthesia on the opposite side, and facial 
paralysis on the side of the lesion. 

5. A lesion in the medulla. This is rare, and is associated 
with paralysis of the cranial nerves, difficult articulation, car- 
diac aud respiratory disturbances, and vomiting. 

6. A unilateral lesion high in the cord (very rare). This 
produces a spastic paralysis on the side affected, and hernianaes- 
thesia on the opposite side (" Brown-SequaixTs paralysis"). 

7. Hysteria. This may be recognized by the history, sex, 
and temperament; by being frequently paroxysmal; by its 
association with sensory disturbances ; by the absence of wast- 
ing and of abnormal electrical reactions ; and by the escape of 
the facial muscles. 

Paraplegia may result from : — 

1. Hemorrhage into the cord at the dorsal region. The 
paralysis develops abruptly, and is associated with complete 
anaesthesia and involvement of the bladder and rectum. 

2. Hemorrhage into the membranes of the cord. The par- 
alysis develops rapidly, but more slowly than the preceding ; 
is associated with intense tearing pains and incomplete anaes- 
thesia. 

3. Some forms of multiple neuritis. This is recognized by 
the pains, the disturbances of sensation, the tenderness over the 
nerve-trunks, and the absence of " girdle pain" and sphincter 
involvement. 

4. Fracture of the vertebrae. 

5. Acute myelitis. The paralysis develops in the course of 
a few days, and is associated with anaesthesia, bedsores, involve- 
ment of the bladder and rectum, loss of reflexes, and wasting 
of the muscles. 

6. Landry's disease (acute ascending paralysis). This de- 
velops in the course of a few days, and is unassociated with 



DISTURBANCES OF MOTION. 313 

anaesthesia, wasting of the muscles, bedsores, or sphincter in- 
volvement. 

7. Chronic m) T elitis. This develops over several years, and 
is associated with numbness and tingling, increased reflexes, 
involvement of the bladder and rectum, and anaesthesia. 

8. Compression of the cord from morbid growths, aneurism, 
or spinal caries. This may be recognized by the history, the 
symptoms of the primary disease, the anaesthesia or hyper- 
esthesia, and the intense pains radiating along the line of the 
spinal nerves. 

9. Lateral sclerosis. This develops slowly and is associated 
with a spastic condition of the muscles and with increased 
reflexes, and lacks sensory disturbances. 

10. Injury of the brain in delivery (spastic paraplegia of 
infants). The symptoms resemble lateral sclerosis, and are 
often associated with imbecility or idiocy. 

11. Hysteria. This may be recognized by the history, sex, 
and temperament ; by being frequently paroxysmal ; and by 
the absence of wasting and of abnormal electrical reactions. 

12. Caisson disease (divers' paralysis). The history will 
establish the diagnosis. 

Convulsions. 

A convulsion is a condition in which there are excessive 
muscular contractions, continued or intermittent, dependent 
upon an involuntary discharge of motor impulses from the 
nerve-centres. 

Intermittent contractions are termed clonic ; continued con- 
tractions, tonic. 

Convulsions may be general or local. The term spasm is 
sometimes applied to the latter. 

There- is no real line of distinction between convulsions, 
choreiform movements, and tremors. 

Varieties of Convulsions. — Three varieties are frequently 
made : (1) Epileptiform ; (2) tetanic ; (3) hysteroidal. 

Epileptiform Convulsions.— In this form there is uncon- 
sciousness, and the movements are for the most part clonic. 
Epileptiform convulsions may result from : — 



314 DISEASES OF THE NERVOUS SYSTEM. 

1. Idiopathic epilepsy. This condition usually develops 
before puberty, and the convulsions are general and are 
unassociated with any definite cause. 

2. Organic brain disease. In this condition there may be 
a history of syphilis or of injury; the convulsions maybe 
local, or begin as such and become general ; and there may be 
concomitant symptoms of cerebral disease. 

3. Toxic agents in the blood. Alcoholism, the infectious 
fevers, and uraemia are frequently associated with convulsions. 

4. Reflex irritation. Such convulsions are usually observed 
in young children, and result from gastric irritation, an ad- 
herent prepuce, intestinal parasites, or teething. Convulsive 
seizures sometimes result from the injection of substances into 
the pleural sac for the cure of hydrothorax. 

5. Cerebral ausemia. Such convulsions are seen after pro- 
fuse hemorrhage, in fatty heart, and in poisoning from cardiac 
paralyzants like aconite and veratrum viride. 

Eclampsia. This term Is applied to designate accidental 
convulsions, such as the convulsions of childhood resulting 
from reflex irritation, and the convulsions of pregnancy or 
the puerperium, resulting from toxic materials retained in the 
blood. 

Tetanic Convulsions. — In this form the discharges emanate 
from the spinal cord, and are not associated with a loss of con- 
sciousness. Tetanic convulsions may result from : — 

1. Tetanus. This is recognized by the. history of a wound, 
the tonic character of the convulsions, the early involvement 
of the jaw, and the absence of fever. 

2. Spinal meningitis. This is recognized by exquisite pain 
in the back, fever, and late involvement of the jaw. 

3. Strychnia-poisoning. This is recognized by the history, 
the intermittent character of the convulsions, the absence of 
fever, and the escape of the muscles of the jaw until very late. 

4. Tetany. In this condition the extremities are chiefly in- 
volved; the convulsions are intermittent, and can be produced 
by pressure on the nerves and arteries of the affected limbs. 

Hysteroidal Convulsions. — These are manifestations of hys- 
teria, and in them consciousness is only partially or apparently 
lost. They are not preceded by an aura, but sometimes by a 



DISTURBANCES OF MOTION. 315 

sensation of a ball in the throat — the "globus hystericus ;" the 
eyes are partially closed ; the face expresses some emotion ; 
the tongue is not bitten ; the movements are tonic, or if clonic, 
appear wilful ; the paroxysm is of long duration ; and the 
patient frequently weeps or laughs. 

Local Convulsions or Spasm. — /Spasm of the face may result 
from a (1) cortical lesion in the inferior portion of the ascend- 
ing frontal convolution ; (2) from tic convulsif — a condition 
occurring in young children, affecting the facial and neighbor- 
ing muscles, and associated with mimicry, a tendency to use 
profane language, and various mental disturbances ; (3) from 
habit (habit- chorea) ; and sometimes from (4) tic douloureux — 
neuralgia of the fifth nerve. 

Temporary spasms of one arm or one leg are usually mani- 
festations of Jacksonian epilepsy (focal epilepsy), but they 
sometimes result from hysteria. 

Spasm of the hand developing ichen the member is put to use 
may result from writers' cramp, Thomsen's disease, or 
hysteria. 

Spasm of the cervical muscles (wry-neck, torticollis) may 
result from congenital shortening of the sterno-mastoid, myal- 
gia, hysteria, caries of the vertebrae, or the irritation of en- 
larged cervical glands. 

Spasms of the larynx, oesophagus, and diaphragm (hiccough) 
have already been discussed. 

Saltatory Spasm. — This term is employed to designate a 
condition allied to hysteria, in which a violent spasm seizes the 
muscles of the leg as soon as the feet touch the ground, and 
as a result the patient is thrown violently into the air. 

Salaam Convulsions. — These consist of violent paroxysmal 
bobbing movements of the head or trunk, and may be asso- 
ciated with hysteria, chorea, or rarely, organic brain disease. 

Choreiform Movements. 

These are coarse, jerky, irregular, involuntary movements 
which more or less simulate purposive movements. They may 
result from : — 

1. Idiopathic chorea (St. Vitus's dance). This disease is 



316 DISEASES OF THE NERVOUS SYSTEM. 

seen in children ; is usually mild ; runs a course of several 
weeks ; and is prone to be followed by endocarditis. 

2. Chorea insaniens. A grave disease occurring in adults, 
especially pregnant women, and characterized by violent move- 
ments, delirium, and fever. 

3. Huntingdon's chorea (chronic chorea). An affection oc- 
curring in adult life, generally hereditary, and characterized 
by irregular movements, disturbance of speech, and increasing 
dementia. 

4. Organic brain disease. Choreiform movements are fre- 
quently observed in cerebral palsies of children ; they may 
also develop on one side of the body before an attack of apo- 
plexy (pre-hemiplegic chorea), or in the paralyzed members 
after the hemorrhage (post-hemiplegic chorea). 

5. Peripheral irritation. Choreiform movements sometimes 
develop in pregnancy, and are occasionally noted in stumps 
after amputation. 

6. Habit. Children frequently acquire, through constant 
repetition or mimicry, choreiform movements which may last 
indefinitely. 

7. Hysteria. The marked rhythmical character of the 
movements and the history will aid in the recognition of 
hysterical chorea. 

8. Disseminated cerebro-spinal sclerosis. This disease usu- 
ally induces tremors, but not uncommonly the movements are 
choreiform. The increased reflexes, the nystagmus, the loss 
of power, the spastic gait, and the impairment of intellect 
will aid in its recognition. 

9. Paramyoclonus multiplex. A very rare disease, of un- 
known origin, characterized by continued or paroxysmal 
choreiform movements which develop or increase under ex- 
citement or movement. 

Athetosis. 

This term was employed by Hammond to designate certain 
movements occurring chiefly in the hands and feet, and charac- 
terized by slow twisting, intertwining, separation, and exten- 
sion of the fingers and toes. Athetosis is frequently observed 



DISTURBANCES OF MOTION. 317 

in the cerebral palsies of children, and it occasionally occurs 
in adults as a result of lesions in the basal ganglia. 

Tremors. 

A tremor is a fine vibratory movement due to the alternate 
contraction and relaxation of antagonistic muscles. Tremors 
are observed in the following conditions : — 

1. They may exist from birth unassociated with other 
symptoms. 

2. They may depend upon a lowered tone of the nervous 
system, being frequently observed in neurasthenia and in the 
convalescence from acute disease. 

3. They may be toxic, resulting from alcoholism or mer- 
curial poisoning. 

4. They may be due to old age. 

5. They are frequently a symptom of organic disease of the 
brain and cord ; as such, they are met with in paretic dementia, 
and especially in disseminated sclerosis. 

6. They may be the chief symptom in paralysis agitans. 

7. They may be hysterical. 

The Gait. 

The Ataxic Gait. — In locomotor ataxia the patient raises 
the foot high, throws it forward, and brings it down suddenly, 
so that the whole sole comes in contact with the floor at once. 

Spastic Gait. — In spastic paraplegia the movements are 
stiff, the knees come together, the leg drags behind, and the 
toe catches the ground. 

Festination. — This term is applied to the gait of advanced 
paralysis agitans; in walking, the body inclines more and 
more forward, and the steps grow faster and faster until the 
patient falls, straightens himself by an effort, or finds support 
in some neighboring object. 

Steppage Gait. — In chronic multiple neuritis the patient 
raises the foot high, turns the toe up, and brings the heel down 
first. 

The Gait of Pseudo-muscular Hypertrophy. — The feet are 
wide apart, the belly protrudes, and the movements are clumsy 
and waddling. 



318 DISEASES OF THE NERVOUS SYSTEM. 

Titubation. — This term is applied to the peculiar gait ob- 
served in lesions of the cerebellum. It resembles the gait of 
locomotor ataxia, but is much more staggering. It is not de- 
pendent upon loss of coordination, for in lying down the 
patient can perfectly control his movements. The absence of 
the Argyll-Robertson pupil, of sharp pains, and of diminished 
reflexes will separate cerebellar disease from locomotor ataxia. 

The Reflexes. 

The " tendon reflexes" were formerly thought to be a pure 
reflex phenomenon, but the tendency at present is to regard 
them as resulting from the contraction of the muscle itself. 
But that the muscle shall contract, it must receive certain 
impulses from the cord, which keep it in a condition of irrita- 
bility. It follows, therefore, that reflexes are dependent upon 
the condition of the cord as well as of the. muscles. 

The Knee-jerk, or Patellar Tendon Reflex. — This is ob- 
tained by tapping the quadriceps tendon between its insertion 
and the patella while the leg is crossed over its fellow. 

The knee-jerk is increased in the following conditions : — 

1 . Frequently in organic disease of the brain, probably from 
irritation of the cord. 

2. In lesion of the cord above the lumbar enlargement, 
probably from cutting off the influence of the reflex inhibiting 
centre in the upper part of the cord. 

3. In disseminated cerebro-spinal sclerosis and in lateral 
sclerosis. 

4. In irritability of the cord, as in mania, hysteria, strych- 
nia-poisoning, and spinal meningitis. 

The knee-jerk is diminished or absent in the following con- 
ditions : — 

1. Degeneration of the muscle, as in pseudo-muscular hy- 
pertrophy. 

2. In lesions of the nerves which cut off the impulse from 
the cord — as neuritis. 

3. In lesion of the posterior columns of the cord, as in loco- 
motor ataxia. 

4. In poliomyelitis, acute and chronic (the anterior gray 
matter is part of the reflex centre). 



DISTURBANCES OF .MOTION. 



319 



5. In advanced myelitis, when the cord is sufficiently 
injured. 

6. In exhaustion of the spiual centres, as after prolonged 
laborious work. 

7. In poisoning from drugs which depress the cord, as anti- 
mony, chloral, etc. 

Ankle-clonus. — This consists of vibratory movements 
obtained by supporting the tench- Achilles with one hand, while 
the foot is strongly flexed with the other. It can rarely be 
obtained in health, but is often marked in hysteria and in 
lateral sclerosis. 

Arm-jerk. — This is obtained by striking the biceps tendon 
at the elbow, or the triceps tendon above the olecranon. 

Jaw-jerk. — This is obtained by tapping the jaw while the 
mouth is partially open. 

The Superficial Reflexes, — These are probably true reflexes, 
and consist in muscular contractions resulting from irritation 
of the skin. 

The following table is based upon the description given by 
Ross in his Handbook of Nervous Diseases : — 



The Reflex, 
Plantar . 

Gluteal . 

Cremasteric 

Abdominal . 
Epigastric . 

Erector Spinal 

Scapular . . 

Palmar . . . 



Produced by 

Tickling the sole of the 

foot. 
Stimulating the skin over 

the huttock. 
I Stimulating the skin on 

the inner side of tlie 

thigh. 
Stroking the skin on the 

side of the abdomen. 
Stimulating the sides of 

the chest in the fifth and 

sixth intercostal spaces. 
Irritation from the angle 

of the scapula to the 

iliac crest. 
Irritation of the scapular 

region. 



Tickling the palm. 



Depends upon Integrity of 

The lower end of the cord 
(conns medullaris). 

Loops through the fourth 
and fifth lumbar nerves. 

First and second pairs of 
lumbar nerves. 

The arcs from the eighth to 

the twelfth dorsal nerves. 
The arcs from the fourth 

to the seventh pairs gf 

dorsal nerves. 
The arcs in the dorsal 

region of the cord. 

The arcs of the upper two 
or three dorsal and the 
lower two or three cervi- 
cal nerves. 

The arcs through the 
greater part of the cervi- 
cal enlargement. 



320 DISEASES OF THE NERVOUS SYSTEM. 

The chief cranial reflexes are contraction of the palatal 
muscles by irritation of the fauces ; sneezing, by irritation of 
the nares ; cough, by irritation of the larynx ; closure of the 
eyelids, by irritation of the conjunctiva; and contraction of 
the iris, by light. 

Paradoxical Contraction. (Westphal.) — This is a peculiar 
phenomenon consisting of a tetanic contraction of the tibialis 
anticus, lasting for several minutes, and induced by forciblv 
Hexing the foot on the leg. Its cause is unknown. It has 
been observed in early locomotor ataxia, multiple sclerosis, 
hysteria, and paralysis agitans. 



DISTURBANCES OF SENSATION. 

These consist chiefly in a loss of sensation — anaesthesia ; in- 
creased sensation — hyperesthesia ; certain abnormal sensations 
— paraesthesia ; and subjective painful sensations — neuralgia. 

Anaesthesia. 

Ordinary cutaneous sensibility may be tested by the prick 
of a pin, by a pinch, or by the faradic current. 

Anaesthesia results from interruption of the sensory tract in 
the nerves, as by neuritis ; from interruption of the sensory 
tract in the cord or brain ; from organic disease of the sensory 
area of the brain ; from the action of toxic substances on the 
nerves or centres; from certain functional conditions like 
hysteria ; and from reflex irritation. 

Hemianesthesia. — A loss of sensation on a lateral half of 
the body. It may result from : — 

1. Hysteria. This is often unassociated with paralysis of 
motion, and may be recognized by the history, sex, and tem- 
perament of the patient ; by the paroxysmal character of the 
anaesthesia ; and by exclusion of other causes. 

2. A unilateral lesion high in the cord. This is very rare, 
and may be recognized by being associated with hemiplegia on 
the opposite side. 

3. A lesion of the medulla (very rare). The hemianses- 
thesia is usually associated with hemiplegia, paralysis of the 



DISTURBANCES OF SENSATION. IVli 

cranial nerves, difficult swallowing, and cardiac and respiratory 
disturbances. 

4. A lesion in the pons. The hemianesthesia is often 
associated with hemiplegia on the same side, and facial palsy 
on the opposite side. 

5. A lesion in the cms, or peduncle. The hemianesthesia 
is often associated with hemiplegia on the same side and 
paralysis of the oculomotor nerve on the opposite side. 

6. A lesion of the posterior limb of the internal capsule, or 
of the optic thalamus pressing on the capsule. 

7. A lesion of the occipital cortex. 

Monancesthesia. — A loss of sensation in one member. It 
may result from hysteria, from a focal lesion of the occipital 
cortex, or from a lesion of the nerves supplying the member. 

Paranesthesia. — A loss of sensation in all parts below the 
waist. It may result from hysteria, organic diseases of the 
cord, neuritis of the lower extremities, or reflex irritation. 

Thermo-ancesthesia. — -Insensibility to heat or cold occurring 
as an independent condition. It is sometimes observed in 
hysteria and syringo-myelia. 

Analgesia. — Insensibility to pain. It is sometimes observed 
in hysteria, in syringo-myelia, and in lesions of the spinal 
cord. 

Retardation of Sensations. — This is frequently observed in 
all forms of anaesthesia, but especially in the anaesthesia of loco- 
motor ataxia. 

The Sense of Pressure. — This is tested by blocks of wood 
loaded with lead, of diiferent weights, the arm being held on 
a table so as to exclude the muscular sense. Partial paralysis 
of this sense is often noted in locomotor ataxia. 

The Sense of Space. — The distance at which two points of 
contact can be recognized as two points. Normally the dis- 
tance varies in diiferent parts and in diiferent individuals. 

On the cheek it is 11-15 millimeters. 

On the forehead, 22 millimeters. 

On the forearm, 40 millimeters. 

On the chest, 45 millimeters. 

On the thigh, 77 millimeters. 

On the leg, 40 millimeters. 
21 



322 DISEASES OF THE NERVOUS SYSTEM. 

On the palm of the hand, 8-12 millimeters. 

On the back of the hand, 31 millimeters. 

Hyperesthesia is increased sensibility to external impres- 
sions. 

It is commonly observed in hysteria, especially in connection 
with the joints, breasts, genitalia, and spine. It is also ob- 
served in neurasthenia, and in beginning inflammation of the 
nerves and of the cerebro-spinal meninges. 

Paresthesia. — This term is used to indicate certain disa- 
greeable subjective phenomena, such as numbness, tingling, 
itching, creeping, and " pins and needles." 

Paresthesia is observed in many conditions, as hysteria, 
spinal sclerosis, neurasthenia, and injury or inflammation of 
the nerves. 

Girdle Sensation. — The sense of having a girdle or tight band 
around the trunk. It is frequently observed in spinal sclerosis. 

Neuralgia. — This consists of paroxysms of severe pain 
radiating along the line of the nerve-trunks. The pain is re- 
lieved by pressure, but there are tender spots (points doulou- 
reux) where the nerve makes its exit from bony canals or 
muscular coverings. 

Lightning-pains. — This term is applied to the sharp lancinat- 
ing pains observed in locomotor ataxia. They usually occur 
in the extremities, and may be mistaken for rheumatism. 

Causalgia. — This term has been applied by S. Weir Mit- 
chell to an intensely burning sensation generally observed in 
"glossy skin." 

Muscular Sensibility. — This term is applied to the appreci- 
ation of the sensation which attends the contraction of a muscle 
under the faradic current. 

Muscular Sense. — This is the sense by which weight, mus- 
cular effort, and position are determined. It is often defective 
in hysteria, locomotor ataxia, and in many forms of paralysis. 

DISTURBANCES OF NUTRITION. 

These consist in atrophy of the muscles, changes in electro- 
muscular contractility, tissue-metamorphoses, and in certain 
abnormalities of the appendages. 



DISTURBANCES OF NUTRITION. 323 

Muscular Atrophy. 

Atrophy, or wasting of the muscles results from : — 

1. Inactivity. Cerebral palsies may thus be associated with 
slow wasting. 

2. Lesions of the trophic cells in the anterior gray horns of 
the cord, as in acute and chronic poliomyelitis. 

3. Lesions of the nerves, such as neuritis or traumatism. 

4. Certain diseases of the muscles themselves, as idiopathic 
muscular atrophy. 

The atrophy which attends chronic affections of the joints 
probably results from neuritis. 

The Reaction of Degeneration. 

In muscular paralysis there may be simply diminished elec- 
trical excitability. This is termed a quantitative change. In 
some cases, however, there is a complete reversal of the normal 
phenomena. This is termed a qualitative change, or the reaction 
of degeneration. 

The reactions of degeneration are obtained with the galvanic 
current applied to muscles in the advanced stage of degeneration. 

The subjoined table, setting forth the electro-muscular 
phenomena in health and disease, follows closely the description 
ofH. C. Wood:— 

The anode — the positive pole ; the cathode— the negative 
pole. When a galvanic current of moderate strength is em- 
ployed, and the cathode is placed over the normal muscle, a 
strong contraction occurs when the circuit is closed ; when the 
anode is placed over the muscle the contraction is much less ; 
in neither case is there any contraction when the current is 
broken. When a strong current is used contractions are pro- 
duced, and the anodal contraction is greater than the cathodal. 
The reaction of degeneration consists in a reversal of these 
phenomena. 



324 DISEASES OF THE NERVOUS SYSTEM. 



Normal muscle. 

A nodal closing contraction (AnCIC) is less than the catho- 
dal closing contraction (CaCIC). 

Anodal opening contraction (AnOC) is greater than the 
cathodal opening contraction (CaOC). 

Muscle in first stage of degeneration. 

Anodal closing contraction (AnCIC) equals the cathodal 
closing contraction (CaCIC). 

Anodal opening contraction (AnOC) equals the cathodal 
opening contraction (CaOC). 

Muscle in advanced stage of degeneration. 

Anodal closing contraction (AnCIC) is greater than the 
cathodal closing contraction (CaCIC). 

Anodal opening contraction (AnOC) is less than the cathodal 
opening contraction (CaOC). 

The reactions of degeneration are observed in diseases which 
destroy the trophic cells in the anterior gray horns of the cord 
or which cut off their influence. Thus they are observed in 
acute and advanced chronic poliomyelitis, in acute central mye- 
litis, in severe neuritis, and after section or compression of the 
nerves. 

Arthropathies. 

An arthropathy is a degenerative affection of the joints, 
characterized by marked swelling due to effusion, erosion of 
the cartilages, relaxation and calcification of the ligaments, and 
atrophy of the heads of the bones. Arthropathies are observed 
especially in locomotor ataxia and in cerebral hemiplegia. 
Some regard the joint-phenomena of rheumatoid arthritis as 
belonging to this class. 

Myxcedema. 

Myxcedema consists of an overgrowth of mucoid tissue in 
the subcutaneous tissues ; it occurs as an idiopathic affection ; 



DISTURBANCES OF CONSCIOUSNESS. 325 

sometimes after the removal of the thyroid gland ; and as a 
symptom of cretinism. 

Ulceration Resulting from Perverted 
Nutrition. 

Acute Decubitus. — This term is applied to ulcers appearing 
on parts subjected to pressure, in a few hours or days, after 
the occurrence of a severe cerebral or spinal lesion. 

Chronic Decubitus. — This term is applied to the ulcers which 
ultimately appear on parts subjected to pressure in the course 
of chronic spinal affections. 

Perforating Ulcer of the Foot. — This term is applied to an 
undermining ulcer of the foot most commonly observed in 
locomotor ataxia. It frequently penetrates the deep structures' 
and involves the bones. 

Symmetrical Gangrene (ReynauoVs Disease). — This is a gan- 
grenous affection involving the fingers, toes, tip of the nose, 
or ears. It arises spontaneously, and is probably due to a 
vaso-motor spasm. 

Trophic Affections of the Skin. — Herpes, scleroderma, 
vitiligo, chloasma, and the "glossy skin" following injuries 
of the nerve-trunks, are illustrations of this class of trophic 
phenomena. 

Trophic Affections of the Hair and Nails. — After injury of 
the nerves and in neuritis the nails often become dry, brittle, 
and cracked. Under similar conditions there may be a loss of 
hair, an overgrowth of hair, or a change in the color of the 
hair. 

DISTURBANCES OF CONSCIOUSNESS. 
Coma. 

Coma is a condition of unconsciousness from which the 
patient cannot be aroused. 

Temporary unconsciousness, due to anaemia of the brain, 
is termed syncope, which may be recognized by the extreme 
pallor, weak pulse, and feeble heart-sounds. 



326 DISEASES OF THE NERVOUS SYSTEM. 

1. Coma may result from traumatism. This cau only be 
recognized by the history or the local evidence of injury. 

2. Organic Disease of the Brain. — The most common cause 
under this head is apoplexy, which may be recognized by the 
history, the age, the condition of the arteries, and by evidences 
of paralysis, such as unnatural relaxation or rigidity on one 
side of the body, conjugate deviation of the eyes, or a higher 
temperature in one axilla. 

3. Epilepsy. — The coma of epilepsy is usually of short dura- 
tion. It may be recognized by the history, by the bloody 
saliva, by the presence of scars on the tongue from previous 
attacks, and by the exclusion of other causes. 

4. Thermic Fever (Sunstroke). — The temperature of the day 
or of the room in which the patient is found, the extremely 
high body-temperature, and the absence of other causes will 
usually prevent an error in diagnosis. 

5. Certain Drugs. — Under this head come alcoholism and 
opium-poisoning. In alcoholism the patient can generally be 
aroused by shouting in the ear, there is the odor on the breath, 
and there is an absence of other cause. 

In opium-poisoning the pupils are small, the respirations 
are slow, the temperature is normal or subnormal ; there 
may be the odor of laudanum on the breath. The diagnosis 
will be aided by the exclusion of other causes. 

6. Uraemia. — In this condition there is a urinous odor on 
the breath ; the aortic second sound is accentuated ; the urine 
contains albumin ; the temperature may be above or below 
normal ; the pupils are usually small, and there is no evidence 
of other cause. 

7. The Infectious Fevers. — The history is sufficient to make 
the diagnosis. Pernicious malarial fever may produce sudden 
coma, and in this condition the examination of the blood 
would render a diagnosis possible. 

8. Hysteria. — The history, age, and sex of the patient, and 
the absence of other cause will usually prevent an error in 
diagnosis. 



DISTURBANCES OF THE SPECIAL SENSES. 327 

Trance. 

In this condition the patient lies for several days apparently 
dead, the pulse and respiration being imperceptible. It is 
usually a manifestation of hysteria. 

Somnambulism. 

A dreamlike state, in which the patient performs auto- 
matically various feats — such as walking, singing, writing, etc. 
Mild forms, such as talking and walking in sleep, may occur 
in health. More marked manifestations occur in hysteria and 
in hypnotism. 

Ecstasy. 

A condition of apparent insensibility in which the mind is 
wholly absorbed with a fancy or delusion. It occurs in the 
hysterical. The dancing mania of the middle ages is a good 
illustration of it. 

Catalepsy. 

This term is applied to attacks characterized by a peculiar 
stiffness of the muscles, and when this is overcome by force 
the limbs can be placed in unnatural positions, which they 
retain for a long time. There may or may not be a loss of 
consciousness and sensation. It is observed in hysteria, hyp- 
notism, in some cases of epilepsy, in some organic diseases of 
the brain, and in certain forms of insanity — notably katatonia. 

DISTURBANCES OF THE SPECIAL SENSES. 

The Eye. 

Myosis. — Contraction of the pupil occurs in many condi- 
tions, notably in locomotor ataxia, paretic dementia, some 
cases of disseminated sclerosis, old age, ura3tnia, and opium- 
poisoning. 

Mydriasis. — Dilatation of the pupil is also observed in 
many conditions, notably in atrophy of the optic nerve, 



328 DISEASES OF THE NERVOUS SYSTEM. 

paralysis of the third nerve, collapse, severe pain, epileptic 
seizures, hysterical attacks, belladonna-poisoning, and in some 
cases of locomotor ataxia and paretic dementia. 

Inequality of the Pupils. — This may occur in health, in 
ocular defects, in organic brain disease, in paretic dementia, 
in locomtor ataxia, and in unilateral paralysis of the oculo- 
motor nerve. 

Argyll-Robertson Pupil. — This is one which fails to respond 
to light, but still accommodates for distance. It is noted espe- 
cially in locomotor ataxia and paretic dementia. 

Conjugate Deviation of the Eyes. — This term is applied to 
the rotation of both eyes away from the median line. It is 
noted especially in apoplexy and in convulsions of organic 
brain disease. 

Nystagmus {Tremor of the Eyeball.) — It may be con- 
genital, associated with certain ocular troubles, or due to 
disease of basal ganglia, especially disseminated sclerosis. 

The Ear. 

Tinnitus Aurium (Xoises in the Ear). — They are observed 
in cerebral hyperemia and anaemia, in diseases of the ear, in 
Meniere's disease, and after the use of certain drugs like 
quinine and salicylic acid. 

Hyperacusis of Hearing. — This is sometimes observed in 
hysteria, in facial paralysis, and in cerebral hyperemia. 

Deafness generally depends upon disease of the ear itself. 

PSYCHICAL DISTURBANCES. 

Delusion. — A delusion is a faulty belief concerning a subject 
capable of physical demonstration, out of which the person 
cannot be reasoned bv adequate methods for the time being. 
(Wood.) 

A systematized delusion is one which the patient endeavors 
to defend by a process of reasoning more or less logical. Sys- 
tematized delusions are especially observed in monomania. 

An unsystematized delusion is one which the patient makes 
no attempt to justify ; he asserts his belief without reason. 



PSYCHICAL DISTURBANCES. 329 

The majority of delusions are unsystematized ; and as such are 
observed in most forms of insanity. 

A fixed delusion is one which the patient retains for a con- 
siderable length of time ; it is frequently systematized. Fixed 
delusions are observed in monomania, paretic dementia, hys- 
terical insanity, and sometimes in melancholia. 

An expansive delusion, or a delusion of grandeur, is one 
which exalts its possessor. The patient conceives that he is 
some noted personage, that he is worth millions of dollars, or 
that he is capable of performing certain marvellous feats. Ex- 
pansive delusions are frequently observed in paretic dementia, 
mania, and hysterical insanity. 

A hypochondriacal delusion is one which depresses its 
possessor. The patient believes that he has committed the 
unpardonable sin, that he is being persecuted, or that he is 
the victim of some dread disease. Hypochondriacal delusions 
are frequently observed in melancholia, alcoholic insanity, and 
in some cases of monomania and paretic dementia. 

Illusion, — An illusion is a perverted perception. Thus in 
delirium tremens the patient may transform every piece of 
furniture into a demon or reptile. 

Hallucination. — An hallucination is a false perception, 
entirely subjective, and not based upon any knowledge derived 
from without. An individual who hears voices and sees ob- 
jects when none exist is the subject of hallucinations. 

Imperative Conception.— A conception which the person 
knows to be false, but which, nevertheless, dominates his 
thoughts and often directs his actions. When he fails to 
recognize the falsity of his conception, it becomes a delusion. 
A morbid impulse is an irresistible desire to commit an act 
which the patient knows to be wrong. It is usually the result 
of an imperative conception. 

Kleptomania is a morbid desire to steal. Pyromania is a 
morbid desire to set fire to buildings, 

Delirium. 

Delirium is a mental state characterized by a rapid flight of 
ideas which are incoherent and often unintelligible. It may 
result from : — 



330 DISEASES OF THE NERVOUS SYSTEM. 

Acute Delirium (BelPs Mania). — A disease arising without 
obvious cause, and characterized by an abrupt onset, active 
delirium, a constant repetition of certain phrases or acts, 
moderate fever, often a bullous eruption, and exhaustion. It 
generally ends fatally in the course of a few weeks. 

Mania. — In this affection the onset is not abrupt. Symp- 
toms of impaired health and mental depression, covering a 
period of several weeks or months, generally precede the out- 
break of the delirium. 

Hysteria. — The history, age, sex, and temperament, and the 
intermittent character of the delirium will aid in the diagnosis. 

One of the Infectious Fevers. — Pneumonia and typhoid fever 
are especially liable to be associated with delirium. The 
physical signs in the former and the abdominal symptoms in 
the latter will usually indicate the diagnosis. 

Uraemia. — The urinous odor of the breath, the high arterial 
tension, the accentuation of the second aortic sound, and the 
presence of albumin and casts in the urine will suggest uraemia. 

Alcoholism. — The history, the appearance of the patient, the 
marked tremors, and frequently terrifying hallucinations will 
indicate alcoholism. 

Inanition. — A form of delirium occasionally arises in the 
course of exhausting diseases. It is associated with pallor, 
feeble pulse, and cold extremities. It is generally of short 
duration, and may be recognized by the circumstances under 
which it develops. 



TUBERCULAR MENINGITIS. 331 

TUBERCULOUS MENINGITIS. 

(Basilar Meningitis, Acute Hydrocephalus.) 

Definition. — An acute inflammation of the cerebral men- 
inges excited by the tubercle bacillus. 

Etiology. — In children the disease may be primary, but 
in adults it is always secondary to a primary focus of tuber- 
culosis in some other part of the body. The majority of cases 
are observed between the second and the fifth years. Heredity, 
bad hygienic surroundings, and poor food (milk from a tuber- 
culous mother) are predisposing factors. 

Pathology. — The basilar meninges are especially involved. 
The pons, crura, and medulla are covered with soft lymph 
which mats together in a common mass the adjacent nerves 
and bloodvessels. The tuberculous character of the inflam- 
mation is manifested by the presence of small yellowish 
nodules which are particularly abundant along the bloodvessels 
in the Sylvian fissures. The amount of fluid in the ventricles 
is increased, and the ependyma is soft and oedematous. The 
cortical substance underlying the affected meninges is also 
soft and infiltrated with leucocytes. 

Symptoms. — The disease usually begins insidiously with 
certain prodromal symptoms. The disposition of the child 
changes ; he ceases to play ; he becomes dull and listless, and 
when disturbed, irritable. Sleep is broken and fitful ; the 
child twitches, grinds his teeth, or starts up with a cry of 
alarm. Headache develops, and is soon associated with fever 
and vomiting; the tongue is coated; the appetite lost ; and 
the bowels constipated. When the disease is fully developed 
the headache becomes intense, and frequently causes from time 
to time a shrill scream — the " hydrocephalic cry.' 7 The 
special senses are abnormally acute, so that bright lights and 
loud sounds cannot be tolerated. The surface is also hyperses- 
thetic, and when touched, the child becomes extremely 
irritable. The temperature is moderately high (102°-103°) ; 
the pulse is at first rapid, but later slow and irregular ; the 
abdominal walls are retracted ; the muscles of the neck rigid ; 
and the pupils contracted. Convulsive seizures frequently 



332 DISEASES OF THE NERVOUS SYSTEM. 

develop ; they may be general or local. The child lies on 
one side with the limbs drawn up, the head strongly retracted, 
and the fingers clinched over the thumb, which is turned 
into the palm. Towards the close of this stage delirium 
develops. 

When the exudate is sufficient in amount to exert marked 
pressure, paralytic phenomena develop. Local palsies, espe- 
cially of the facial muscles, take the place of convulsions ; 
coma follows delirium ; the pupils dilate and the eyes roll up ; 
photophobia is replaced by blindness, and intolerance of 
sound by deafness. If the finger is drawn across the body, 
a bright red line develops and lingers for some minutes; this 
is the tciche cerebrate of Trousseau. The pulse now becomes 
rapid and irregular ; the respiration assumes the Cheyne- 
Stokes type, and the temperature falls. The duration is from 
one to three weeks. 

Diagnosis. Typhoid Fever. — Typhoid fever may closely 
simulate meningitis, especially in the young ; but the early 
development of cerebral symptoms, the irregular fever, the 
slow pulse of the first stage, the retracted abdominal walls, 
the constipation, and the absence of rose-colored spots will 
serve to distinguish meningitis from typhoid fever. 

Simple Meningitis. — An absolute diagnosis may be impos- 
sible, but the history of tuberculosis in the family, the presence 
of tuberculous foci in other parts, the detection of tubercle on 
the retina, and an onset without obvious cause will generally 
indicate the true nature of the case. 

Prognosis. — Absolutely unfavorable. 

Treatment. — The patient should be placed in a quiet, 
dark, well-ventilated room. The diet should be liquid. An 
ice-bag should be applied to the head. Constipation should 
be relieved by enemata. For the headache, restlessness, and 
convulsions, chloral and bromide of potassium are useful, and 
may be given by the rectum. 

J$l Moschi, gr. iij ; 
Camphorse, gr. xv ; 
Chloral, hydrat., gr. viiss ; 
Yitelli ovi, No. i ; 
Aq. destillat., f.^iv.— M. (Simon.) 
Sig. — Wash out the rectum with a simple enema and inject two 
ounces. 



CHRONIC PACHYMENINGITIS. 333 

The administration of ergot and of iodide of potassium, and 
the external application of an ointment of iodoform to the 
shaved scalp have been recommended, but generally prove 
useless. 

SIMPLE LEPTOMENINGITIS. 

(Acute Leptomeningitis, Meningitis of the Convexity.) 

Definition. — An acute inflammation of the pia mater 
not due to tubercle. 

Etiology. — Traumatism, sunstroke, rheumatism, Bright's 
disease, and the infectious fevers, are the usual predisposing 
causes. It occasionally develops from caries of the bone which 
is secondary to middle-ear disease. 

Pathology. — The membranes are opaque, thickened, con- 
gested, adherent, and more or less infiltrated with purulent 
fluid. Generally the convexity is affected, but in some cases, 
as those following middle-ear disease, the base is chiefly in- 
volved. The adjacent cortical substance is also cedematous, 
soft, and injected. 

Symptoms. — Moderate irregular fever, loss of appetite, con- 
stipation, intense headache, intolerance to light and sound, 
contracted pupils, delirium, retraction of the head, convulsions, 
and coma. 

When the base is involved, the symptoms are almost identi- 
cal with those of tuberculous meningitis. 

Prognosis. — Unfavorable, though recovery is not im- 
possible. 

Treatment. — The patient should be placed in a quiet, 
dark, well- ventilated room. An ice-bag should be applied to 
the head. When the patient is robust, wet cups or leeches may 
be applied to thesneck. The diet must be liquid. Constipa- 
tion should be relieved by enemata. Restlessness, headache, 
and convulsions call for chloral and bromide of potassium. 

CHRONIC PACHYMENINGITIS. 

Definition. — Inflammation of the dura mater. 
Etiology. — Inflammation of the external layer may result 
from injury, syphilis, sunstroke, or caries of the bone. In- 



334 DISEASES OF THE NERVOUS SYSTEM. 

flamruation of the internal layer (hemorrhagic pachymeningitis) 
may be secondary to chronic cardiac or renal disease, one of 
the infectious fevers, chronic alcoholism, or especially, insanity. 

Heinorrli agic Pachy nieiii ngitis. 

(Haematoma of the Dura Mater.) 

Pathology. — The membranes are thickened, opaque, and 
more or less adherent. The bloodvessels are dilated. Be- 
tween the membranous layers are frequently observed hemor- 
rhagic effusions ; these vary in extent from slight ecchymoses 
to clots as large as a hen's egg. In some cases the pressure of 
the clots on the convolutions is sufficient to cause the latter to 
atrophy. 

Symptoms. — Often obscure. In some cases there are no 
manifestations during life. When the condition is marked, 
the following phenomena may be observed : Headache, failure 
of memory, impairment of intellect, stupor, contracted pupils, 
local convulsions, or palsies. The symptoms may alternately 
improve and grow worse for a long period. In grave cases, 
associated with extensive hemorrhagic effusion, the symptoms 
resemble apoplexy. 

Diagnosis. — This can rarely be made Avith certainty. 

Prognosis. — Unfavorable. 

Treatment. — Grave cases should be treated as apoplexy. 

HYDROCEPHALUS. 

(Congenital Hydrocephalus, Water on the Brain.) 

Definition. — A condition in which there is an excessive 
accumulation of fluid in the ventricles or arachnoid cavity. 

Etiology. — Acquired Hydrocephalus may develop at any 
period of life, and may result from meningitis, the pressure of 
a tumor, or from one of the causes of general dropsy. 

Congenital Hydrocephalus, the form now under discussion, 
dates from birth or develops in the first few years of life. Its 
cause is unknoAvn ; in some cases it is probably due to a latent 
inflammation of the ependyma of the ventricles. 



HYDROCEPHALUS. 335 

Pathology. — The head is large and round ; the bones are 
thin and translucent ; the sutures and fontanelles are enlarged, 
and. if life has been prolonged, are filled with numerous 
Wormian bones. The convolutions of the brain are flattened 
and the sulci more or less obliterated. In external hydro- 
cephalus the accumulation of fluid is found in the arachnoid sac; 
but in internal hydrocephalus — the most common form — the 
ventricles are greatly distended with a watery fluid of low 
specific gravity, containing a trace of albumin. The epen- 
dyma is often thickened and roughened. Malformations are 
frequently observed, and probably result from the same cause 
which induced the effusion. 

Symptoms. — Sometimes the disease develops before birth, 
and the large head interferes with the delivery of the child. 
In other cases nothing peculiar is observed until the child is 
several months old, when the swelling of the head attracts 
the attention of the parents. The head assumes a globular 
shape ; the fontanelles and sutures remain open ; the face be- 
comes relatively small ; the eyes protrude and are directed 
downward from the pressure of the fluid on the supraorbital 
plates ; the scalp appears thin and stretched ; the superficial 
veins are distended; and the hair becomes scant. In some 
cases the head is so heavy that the thin neck can no longer 
support it, and it falls forward on the breast, 

As a rule, the intelligence is considerably impaired, but ex- 
ceptional cases are marked by precociousness. Motor phe- 
nomena are frequently present : the reflexes are exaggerated ; 
one or more of the members may be the seat of a spastic 
paralysis ; convulsions develop in many cases. 

The duration varies in different cases. The large majority 
soon die of inanition, convulsions, or some intercurrent disease 
to which their reduced vitality makes them an easy prey ; but 
in a few, life is prolonged for many years. 

Diagnosis. — Hydrocephalus must not be mistaken for 
rachitic enlargement of the head. In the latter, the head is 
square instead of globular ; the intelligence is good ; there are 
no motor phenomena ; and bony enlargements are usually 
detected at the ends of the long bones and at the junction of 
the cartilages with the ribs. 



336 DISEASES OF THE NERVOUS SYSTEM. 

Prognosis. — Unfavorable. In a few cases arrest of the 
disease has been spontaneous, or has resulted from aspiration 
of the fluid. 

Treatment. — The treatment is unsatisfactory. Counter- 
irritation and the use of diuretics and absorbents exert no 
influence on the disease. In the majority of cases, beyond 
dietetic and hygienic measures and the occasional use of tonics, 
little can be recommended. In cases where the pressure- 
symptoms are marked, tapping offers some hopes of tem- 
porary relief. After the operation compression of the skull 
should be made by the application of concentric bands of 
adhesive plaster. 

PARETIC DEMENTIA. 

(General Paralysis of the Insane, General Paresis, Chronic 
Meningo-encephalitis.) 

Definition. — A chronic inflammatory affection of the 
cerebral cortex, characterized by a change of disposition, 
failure of memory, mental exaltation, delusions of grandeur, 
tremors, epileptiform seizures, and paralysis. 

Etiology. — Male sex, middle life, prolonged mental strain, 
and excesses are predisposing factors. It may be induced by 
the usual causes of sclerosis, namely, syphilis, alcoholism, lead- 
poisoning, gout, etc. 

Pathology. — The membranes are opaque, thickened, and 
at places, adherent to the brain substance. The cortex is more 
or less atrophied and increased in firmness. Microscopic 
examination reveals an overgrowth of connective tissue and 
degeneration of nerve-fibres and ganglionic cells. 

In some cases similar degenerative changes are observed in 
the posterior and lateral columns of the cord. 

Symptoms. — The disease usually begins insidiously with a 
change in disposition ; the industrious become slothful ; the 
ambitious, apathetic ; the chaste, dissolute ; the liberal, parsi- 
monious ; the complaisant, churlish ; and the truthful, false. 
The energy relaxes, the judgment weakens, and the memory 
fails. As the faculties become impaired, a peculiar egotism 
and mental exaltation develop ; the patient becomes boastful, 



PARETIC DEMENTIA. 337 

loquacious, and easily provoked to furious outbreaks. The 
failure of memory is early noted in writing, by the use of 
wrong letters and the suppression of syllables. At this time 
motor phenomena may be observed : the tongue trembles when 
it is protruded ; the speech is slow, hesitating, and indistinct ; 
the pupils are often unequal ; and the gait is somewhat 
shuffling. 

The most characteristic psychical symptom of fully-de- 
veloped paretic dementia is the delusion of grandeur : the 
patient conceives that he is some distinguished personage, that 
he owns acres of land, or that he is the inventor of some 
wonderful machine. The mind is usually serene and cheerful, 
but periods of depression are not infrequent. The sensibilities 
are blunted and the animal nature emphasized. The mind 
becomes more and more involved ; there is extreme indifference 
to all that transpires ; the appetite is voracious, and in eating 
the patient bolts his food and soils his clothes. The tremor 
of the tongue increases, and spreads to the lips and other parts 
of the face; the speech is indistinct and " scanning ;" the pupils 
fail to respond to light, but still accommodate for distance 
(Argyll-Robertson pupil) ; the reflexes are generally increased. 
Spellsofunconsciousnessresembling_p^^m«/ are not uncommon. 

In the final stage mental power is almost obliterated ; the 
health fails ; the bladder and rectum become unretentive ; the 
gait is more unsteady ; and at last the patient is unable to 
leave his bed. Death usually results from exhaustion or in- 
tercurrent disease. 

Diagnosis. — The insidious change in disposition, failure of 
memory, tremors, Argyll-Robertson pupil, and delusions of 
grandeur are the diagnostic features. 

Cerebral Syjohilis. — In this disease the history, the occur- 
rence of convulsions and of partial facial palsies, the absence 
of delusions of grandeur and of " scanning" speech, and the 
effect of treatment will usually prevent an error in diagnosis. 

Prognosis. — Unfavorable. The course is not uniform ; in 
some cases there are remissions, or lucid intervals, which last 
several months or years. The average duration is three or 
four years. 

Treatment. — Rest of body and mind. Careful attention 
22 



338 DISEASES OF THE NERVOUS SYSTEM. 

to the hygiene. When there is a suspicion of syphilis, iodides 
and mercurials should be given a thorough trial. As a rule, 
patients must be removed to asylums. 

CEREBRAL PARALYSIS IN CHILDREN. 

Definition. — Hemiplegia, diplegia, or paraplegia ap- 
pearing at birth or in the first few years of life, and usually 
associated with atrophy and sclerosis of the cerebral cortex, 
or porencephalus. 

Pathology. — After death one of the following conditions 
is observed : Atrophy and sclerosis of the convolutions ; poren- 
cephalus (a cystic condition of the cortex) ; or more rarely, 
some local obstruction to the cerebral circulation, as from 
hemorrhage, embolism, or thrombosis. The exciting cause of 
the porencephalus and sclerosis is still undetermined. 

Symptoms. — In the hemiplegia variety the onset is sudden, 
and is frequently attended with fever, convulsions, or coma. 
After a few hours or davs these severe symptoms subside, and 
the child is left paralyzed on one side of the body. In rare 
instances the paralysis ultimately disappears and the child is 
restored to health, but in the large majority of cases it persists 
and is followed by secondary rigidity. Imbecility, epilepsy, 
and choreiform or athetoid movements in the affected members 
are very common sequelae. 

The diplegia or paraplegic form frequently dates from birth, 
and is characterized by rigidity and loss of power in all of the 
extremities. The legs suffer more than the arms. Chorei- 
form or athetoid movements are frequently present. Children 
thus affected are generally idiots or imbeciles. Meningeal 
hemorrhage, induced by tedious labor or the use of the for- 
ceps, appears to be responsible for this variety. 

Treatment. —During the convulsive stage an ice-bag 
should be applied to the head, and chloral or bromide admin- 
istered by the mouth or rectum. The paralysis resists treat- 
ment ; but subsequent rigidity may be lessened by massage 
and passive movements, and the deformity by mechanical 
appliances. 1 

1 The above description is based upon Osier's elaborate monograph. 



CEREBRAL HYPEREMIA. 339 

CEREBRAL HYPEREMIA. 

(Congestion of the Brain.) 

Etiology. — Acute congestion, results from exposure to the 
sun ; from the use of certain drugs, like alcohol and nitro- 
glycerine ; from excesssive brain-work ; or from some reflex 
disturbance, as gastric irritation. 

Chronic congestion results from some local obstruction to 
the return of blood from the brain, as by a tumor in the neck ; 
from obstruction to the general circulation, as in chronic heart 
and lung disease ; from the suppression of some habitual dis- 
charge, as the menstrual flow at the menopause ; or from some 
general cause, such as prolonged anxiety, overwork, excesses, 
irregular living, etc. 

Pathology. — The vessels of the meninges and of the 
brain-substance are engorged. 

Symptoms. Acute Form. — Intense headache ; vertigo ; 
intolerance to light and sound ; restlessness ; tinnitus aurium ; 
and sleeplessness, or sleep disturbed by horrible dreams. 

Chronic Form. — Vertigo ; dull headache ; failure of 
memory ; irritability ; inability to concentrate the thoughts ; 
and disturbed sleep. The symptoms grow worse when the re- 
cumbent posture is assumed. Ophthalmoscopic examination 
reveals retinal hyperemia. In marked cases there may be 
exacerbations closely resembling apoplexy, in which there is 
unconsciousness, followed by temporary paresis. 

Prognosis. — Depends on the cause ; when this can be 
removed the prognosis is favorable. 

Treatment. Acute Congestion. — The patient should be 
placed in a darkened, well-ventilated room. The head and 
shoulders should be slightly elevated. An ice-bag should be 
applied to the head. Leeches or wet-cups may be applied to 
the neck. Sedatives like bromide of potassium and aconite 
are useful. Ergot maybe employed for its power to contract 
the vessels. If there is constipation, it should be relieved by a 
brisk saline purge. 

In chronic cases the cause should be ascertained and, if 
possible, removed. The habits of the patient must be regu- 



340 DISEASES OF THE NERVOUS SYSTEM. 

lated. The diet must be light and nutritious. Constipation 
must be relieved by diet or by the occasional use of a saline 
laxative. Sedatives like bromide of potassium and aconite are 
useful. In the apoplectiform attacks venesection is indicated. 

CEREBRAL ANEMIA. 

Etiology. — General cerebral anaemia as a chronic affection 
may result from cardiac disease, especially aortic stenosis. It 
may be associated with general anaemia. It may be due to 
atheromatous obstruction of the arteries. 

Overwork, prolonged emotional excitement, irregular living, 
and excesses are also said to predispose. 

As an acute condition it exists in syncope and shock ; after 
hemorrhage ; after the sudden withdrawal of fluid from the 
abdominal sac ; and after ligation of the carotid artery. 

Symptoms. Acute Form. — Pallor of the face, vertigo, 
confusion of ideas, ringing in the ears, dimness of vision, dila- 
tation of the pupil, nausea, aud a tendency to yawn. In 
extreme anaemia there may be convulsions and coma. 

The chronic form is characterized by vertigo, headache, dis- 
turbed sleep, intolerance to light and sound, irritability of 
temper, failure of memory, inability to concentrate the atten- 
tion on one subject, a tendency to syncope, and extreme lassi- 
tude. The symptoms improve when the patient lies down. 
Ophthalmoscopic examination reveals pallor of the retina. 

Diagnosis. — Cerebral anaemia closely simulates cerebral 
congestion, but in the latter there is no tendency to syncope ; 
the symptoms grow worse when the patient lies down ; and the 
ophthalmoscope reveals retinal hyperemia. 

Prognosis. — Depends on the cause ; when this can be re- 
moved the prognosis is favorable. 

Treatment. — In acute cases diffusible stimulants like 
nitro-glycerin, ammonia, and strychnia are indicated. In 
chronic cases the cause should be ascertained, and if possible, 
removed. When it is due to general anaemia, iron, arsenic, 
and quinine are useful remedies. When dependent on valvu- 
lar disease, rest and the use of digitalis, strophanti] us, or 
strychnia are the remedial measures. 



CEREBRAL HEMORRHAGE. 341 

CEREBRAL HEMORRHAGE. 

( Cerebral Apoplexy . ) 

Etiology. — The affection is most commonly met with in 
the old, in whom the bloodvessels are atheromatous, and in 
the very young, in whom they are naturally weak. All 
causes which lead to degeneration of the arteries, such as 
rheumatism, gout, syphilis, alcoholism, and B right's disease, 
predispose to it. Sufferers from chronic Bright's disease are 
very liable to die of apoplexy on account of the association of 
cardiac hypertrophy with arterial degeneration. Heredity 
predisposes, inasmuch as members of certain families are 
particularly prone to sclerosis of the vessels. The attack 
may be precipitated by mental or physical excitement, alco- , 
holic excess, or some reflex disturbance, as gastric irritation. 
In children it may be excited by a paroxysm of whooping- 
cough or by a convulsion. 

Pathology. — In children the hemorrhage is most com- 
monly cortical ; in adults it is usually within the brain-mass. 
The bloodvessels are generally atheromatous, and are some- 
times the seat of miliary aneurisms. The clot varies greatly 
in size; sometimes it is small, merely a capillary oozing; at 
other times it may fill a hemisphere. Its most common seat 
is the internal capsule — the motor highway between the optic 
thalamus and the corpus striatum. In recent hemorrhages 
the clot is dark and soft, and the surrounding tissue stained 
and more or less lacerated. If the hemorrhage has not been 
very copious, the clot loses it color, shrinks, and is finally 
absorbed, and the damaged cerebral fibres are replaced by 
proliferated connective tissue, which contracts aud forms a 
scar more or less pigmented with hsematoidin. In other cases, 
instead of a scar, a cyst is formed which encloses a clear straw- 
colored fluid. Large effusions in the motor path may produce 
secondary changes — either a softening of the cerebral tissue 
beyond, or a degeneration which travels down the lateral 
column of the cord on the side opposite the lesion. 

Symptoms. — Prodromal symptoms indicating cerebral con- 
gestion frequently precede the attack ; these are headache, 



342 DISEASES OF THE NERVOUS SYSTEM. 

vertigo, disturbed sleep, tinnitus aurium ; or there is a sense 
of numbness or weakness on the side which is to be affected. 
Persistent vomiting sometimes precedes the hemorrhage. 

The Attack. — In many cases the patient falls suddenly un- 
conscious without previous warning. The face is flushed ; 
the eyes are injected ; the lips are blue; the breathing is ster- 
torous ; the pulse is full and slow ; the temperature is at first 
subnormal from shock, but later it is elevated from irritation ; 
and the urine and feces may be passed involuntarily. Convul- 
sive seizures are not infrequent; they result from irritation 
transmitted to the undamaged motor regions. Even while the 
patient is comatose the paralysis can be detected. The head 
and eyes may be strongly rotated to one side (conjugate devia- 
tion) ; one cheek often flaps more than the other ; the pupils 
may be irregular ; any movements which the patient may 
make are restricted to the sound side ; when the affected arm 
is raised and let fall, it drops lifeless or manifests an unnatural 
rigidity ; and occasionally there is a difference of temperature 
in the two axillae. In grave cases the patient does not awake 
from the coma ; the pulse grows feeble ; the respirations assume 
the Cheyne-Stokes type ; the reflexes are abolished ; mucus col- 
lects in the throat and produces a rattling sound ; the tempera- 
ture rises high ; and death results after the lapse of a few hours 
or one or two days. 

In some cases the paralysis develops quite gradually and is 
not attended with unconsciousness. 

Subsequent Symptoms. — When the attack does not prove 
fatal, consciousness is finally restored, and if the hemorrhage 
is in its usual location, there remains a hemiplegia on the 
opposite side. In a few hours the affected muscles become 
rigid from irritation of the motor fibres. This early rigidity 
is termed primary rigidity ; it lasts from a few days to several 
weeks and has no significance from a prognostic standpoint. The 
paralysis is rarely a complete hemiplegia ; the muscles of the 
upper part of the face and thorax usually escape, because they 
are accustomed to act in unison with their fellows on the op- 
posite side, and such muscles are rarely involved in cerebral 
hemiplegia. When the tongue is protruded, it deviates toward 
the paralyzed side. The deep reflexes are exaggerated on 



CEREBRAL HEMORRHAGE. 343 

the affected side. Sensation is unimpaired unless the pos- 
terior limb of the internal capsule is also involved, when there 
is hemianesthesia with hemiplegia. The gait is peculiar ; in 
walking the patient supports the paralyzed arm, and swings 
the leg forward by a rotary movement imparted to it by the 
trunk. When the clot has been small, the paralysis may 
completely disappear. More frequently recovery is only par- 
tial ; the power of the facial muscles is usually restored 
entirely, and the leg improves more than the arm. In unfavor- 
able cases the muscles again become rigid (secondary rigidity) 
from a degenerative process travelling down the lateral column 
of the cord ; this condition is indicative of permanent dis- 
ability. Generally the mental power remains unimpaired, 
but sometimes the symptoms of cerebral softening gradually 
develop. 

Diagnosis. — The coma of apoplexy must be distinguished 
from uramia, opium-poisoning, alcoholism, and sunstroke. The 
age of the patient ; the condition of the arteries ; the evidence 
of paralysis ; the difference of temperature in the two axillae ; 
and the absence of other cause will usually prevent an error in 
diagnosis. 

Embolism. — This usually occurs in earlier life ; it is com- 
monly associated with valvular disease; the paralysis is almost 
invariably on the right side ; aphasia is more common ; there 
is less disturbance of temperature ; and consciousness may not 
be lost. 

Thrombosis. — This also produces hemiplegia, but its de- 
velopment is very gradual. 

Hemiplegia from other Causes. — Tumors and abscess in tlie 
brain may produce hemiplegia, but the latter develops gradu- 
ally and is usually associated with other cerebral phenomena, 
such as persistent headache, vertigo, ocular palsies, choked 
disk, etc. 

Hysterical Hemiplegia. — In hysteria the face escapes ; there 
is frequently anaesthesia on the affected side ; the gait is pecu- 
liar, in that the patient pushes the paralyzed limb instead of 
swinging it. These features together with the age, tempera- 
ment, sex, and mode of onset will usually suggest the true 
cause. 



344 DISEASES OP THE NERVOUS SYSTEM. 



Prognosis. — Always doubtful. Persistent and complete 
unconsciousness, high temperature, loss of reflexes, and embar- 
rassed respiration are unfavorable phenomena. When the at- 
tack does not prove fatal, there is always a probability of 
subsequent ones, for the etiological conditions still remain. 

Treatment. Prophylaxis. — Patients predisposed to apo- 
plexy should lead a quiet life, free from mental and physical 
excitement. The diet should be nutritious, but easily diges- 
tible. Constipation should be relieved by the occasional use of 
a saline laxative. To secure a free return of the blood from 
the brain the clothes at the neck should be loose. 

The Attack. — The head and shoulders should be slightly 
elevated, and an ice-bag applied to the head. Croton oil 
(gtt. j-iij) in a little glycerine or olive oil may be placed on 
the back of the tongue to secure prompt catharsis. If the 
pulse is strong, venesection is indicated and should be con- 
tinued until the pulse softens. Bleeding cannot undo the 
damage already done, but by relieving cerebral congestion it 
may prevent a renewed outpouring. On the other hand, when 
the face is pale and the pulse feeble the hypodermic injection 
of diffusible stimulants, like ammonia and strychnia, is indi- 
cated. When collections of mucus interfere with breathing, the 
patient should be gently turned on his side and the mucus 
removed. 

To prevent the formation of bedsores the position should 
be frequently changed, and the parts subjected to pressure 
thoroughly cleansed. 

Subsequent Treatment. — As other attacks are liable to occur, 
the prophylactic treatment already referred to is applicable 
here. Iodide of potassium (gr. v-x thrice daily) may be ad- 
ministered with the hope of absorbing the clot. After the 
primary rigidity has disappeared, galvanism, massage, and 
passive movements should be applied to the aifected muscles. 
Strychnia by the mouth or injected directly into the muscles is 
often very useful. Even when the paralysis remains, con- 
tractures may be prevented to a considerable extent by 
massage. 






OBSTRUCTION OF THE CEREBRAL ARTERIES. 345 

OBSTRUCTION OF THE CEREBRAL ARTERIES. 

(Embolism, Thrombosis.) 

Etiology. — Cerebral emboli may be derived from the 
valves of the heart in endocarditis ; from an atheromatous plate 
in the aorta ; or from a clot in the heart or in the sac of an 
aneurism. Obstruction from embolism may occur at any 
age, but it is far more commonly observed in young adults 
than at the extremes of life. 

Thrombi are clots formed in the vessels, and a weak heart 
and arterial degeneration are the predisposing factors. They 
are usually observed in advanced years, but those dependent 
on syphilitic arteritis frequently occur in early adult or middle 
life. 

Pathology. — Emboli are most frequently found in a 
brauch of the left middle cerebral artery. When the artery 
obstructed is a large one, the part beyond usually becomes 
pale and soft; but sometimes it presents the appearance of 
an infarction and is infiltrated with blood. Subsequently, 
microscopic examination reveals fatty degeneration of the 
nervous elements and more or less pigmentation from extra- 
vasated blood. If the area affected is small, absorption may 
follow and scar-tissue be substituted. 

Thrombi are usually found in the middle cerebral, basilar, 
or vertebral arteries, and are followed by similar changes. 

Symptoms. — An embolus lodging in the middle cerebral 
artery usually causes abrupt hemiplegia, and frequently 
aphasia. There may be no prodromes, and consciousness is 
often preserved during the seizure. 

When the basilar artery is obstructed, there may be exten- 
sive paralysis on both sides of the body, and later, symptoms 
of bulbar disease, namely, paralysis of the lips, pharynx, 
and oesophagus, disturbance of the heart, and Cheyne-Stokes 
breathing. 

In thrombosis the symptoms are similar to embolism, but they 
develop very slowly, and are frequently preceded by prodromes 
indicating disturbed cerebral circulation, such as headache, 
vertigo, disturbed sleep, failure of memory, numbness and 
tingling in the limbs to be affected. 



346 DISEASES OF THE NERVOUS SYSTEM. 

Subsequent Symptoms. — In both embolism and thrombosis, 
if the artery obstructed has been large, the paralysis persists 
and symptoms of cerebral softening appear — namely, failure 
of memory, vertigo, headache, disturbed sleep, great irrita- 
bility, and finally dementia. 

Diagnosis. — Cerebral embolism closely resembles apoplexy, 
and sometimes it may be impossible to distinguish between the 
two conditions. The following are the diagnostic features : — 

Embolism is generally associated with valvular disease ; it 
commonly occurs in the young ; prodromes are frequently ab- 
sent ; the left middle cerebral artery being almost invariably 
involved, the hemiplegia is on the right side ; aphasia is more 
common in embolism than in hemorrhage ; there is much less 
disturbance of temperature after embolism than after apo- 
plexy ; consciousness is less apt to be lost in embolism than in 
apoplexy. 

Prognosis. — In embolism it is very doubtful ; recovery 
may follow, but often the paralysis remains. In thrombosis 
there is very little hope of recovery, unless the cause is syphilis. 

Treatment. — After obstruction from embolism the patient 
shoidd be kept at absolute rest for a few days, and subsequently 
the paralysis treated as after apoplexy. In thrombosis treat- 
ment is of no avail, save in syphilitic subjects, when mercurial 
inunctions should be employed freely and the bichloride given 
by the mouth. 

CEREBRAL SOFTENING. 

Definition. — Degeneration of the brain-substance resulting 
from perverted nutrition. 

Etiology. — Local softening may result from obstruction 
to the circulation by a tumor, embolism, thrombosis, or clot. 
Extensive softening may result from prolonged cerebral anaemia 
or congestion. It is most frequently observed in old people in 
association with atheromatous arteries. 

Pathology. — The affected portion is dull white or reddish- 
yellow, according to the amount of blood-pigment present ; 
and is less firm than the surrounding brain-substance. Some- 
times it is so soft that when the brain is cut a creamy fluid 



MORBID GROWTHS IN THE BRAIN. 347 

flows out. Microscopic examination reveals destruction of the 
nerve-elements and their substitution by granular debris and 
fat-drops. 

Symptoms. — When extensive the symptoms are : Failure 
of memory, irritability of temper, vertigo, headache, partial 
palsies, cutaneous anaesthesia or paresthesia, delusions, and 
finally dementia. 

Local softening may be manifested by local paralysis. 

Diagnosis. Cerebral Tumor. — Tumors usually develop in 
younger subjects ; the headache is more severe ; choked disk 
is frequently observed. 

Prognosis.— Unfavorable. 

Treatment. — Palliative. 

MORBID GROWTHS IN THE BRAIN. 

(Tumors of the Brain.) 

Etiology. — Early adult life, male sex, and perhaps trau- 
matism predispose. Heredity also predisposes to the extent 
that it favors the development of cancer, gumma, and tubercle. 

Varieties. — Tubercle, gumma, glioma, cysts, sarcoma, 
and carcinoma are the most common varieties. Less frequently 
fibroma, psammoma, and lipoma are observed. 

Pathology. — Tuberculous tumors, or tyromata, vary in size 
from a pea to an egg ; they may be single or multiple ; and 
are usually observed in the young. 

Gumma. — This appears as a round, yellow, caseous mass, 
and is nearly always on the surface of the brain, into which it 
grows from the overlying membranes. It is usually met with 
between thirty and forty. 

Glioma. — This tumor is found almost exclusively in the 
brain. It arises from the neuroglia, and may be soft like 
brain-substance or firm like fibrous tissue. It is chiefly met 
with in the young. 

Cysts. — These are usually congenital (porencephalus), but 
sometimes they result from the taenia echinococcus (hydatid 
cyst). 

Sarcoma. — This is usually a diffuse tumor, and grows from 
the membranes. 



348 DISEASES OF THE NERVOUS SYSTEM. 

Carcinoma. — This is nearly always secondary and multiple. 

Symptoms. — (1) Headache is rarely absent; it may be 
localized and associated with tenderness on pressure. (2) 
Vomiting is a common symptom, especially in tumors of the 
base of the brain ; it is often unassociated with nausea and 
does not relieve the attending headache. (3) Ocular phe- 
nomena, as optic neuritis, or choked disk, optic atrophy, diplo- 
pia, hemianopia, blindness, and irregular pupils. (4) Vertigo. 
(5) Psychical phenomena, as failure of memory, irritability 
of temper, depression of spirits, and dementia. (6) Symp- 
toms resulting from local pressure, such as local palsies or 
convulsions, aphasia, and local anaesthesia. 

Diagnosis. — This includes: (1) the existence of a tumor, 
(2) its character, and (3) its location. 

The existence of a tumor is determined by the headache, 
vomiting, optic neuritis, and symptoms of local pressure. 

Abscess. — Cerebral tumor must be distinguished from 
abscess. The latter usually results from traumatism or is 
secondary to a focus of suppuration in some other part of the 
body ; its progress is more rapid ; choked disk is rare ; and 
there is often febrile disturbance. 

Chronic Meningitis. — In this affection the symptoms indi- 
cate a diffuse lesion; disturbances of temper, memory, and sleep 
are more marked; and optic neuritis is rarely observed. 

The Character of the Growth. — This cannot always be deter- 
mined. The early age, the rapid progress, and the family 
history may suggest tubercle. The early age, slow progress, 
and mild pressure-symptoms may suggest glioma. The his- 
tory, age, and concomitant symptoms will indicate syphilis. 
The presence of a primary growth will lead to the diagnosis 
of cancer. 

Location. — The following facts relating to cerebral localiza- 
tion will aid in determining the location of the growth. 

Motor area. This consists of the ascending frontal and 
ascending parietal convolutions, and the paracentral lobule 
which lies along the median fissure. When the tumor irritates 
the part, convulsion results ; when it exerts enough pressure 
to destroy function, paralysis results. 



MORBID GROWTHS IN THE BRAIN. 349 

Paracentral lobule — spasm or paralysis of a lower ex- 
tremity. 

Central portion of the motor area — spasm or paralysis of one 
arm. 

The lower portion of the motor area — spasm or paralysis of 
one side of the face. 

Posterior part of the third frontal convolution (left side) — 
aphasia. 

Anterior portion of the frontal lobes — marked physical symp- 
toms. 

Temporal lobe, first and second convolutions (left side) — word- 
deafness. 

Parietal occipital lobe — no peculiar symptoms. 

Angular and supramarginal gyri (left side) — word-blindness 
and mind-blindness. 

Occipital lobe — hemianopia, and sometimes word-blindness 
and mind-blindness. 

Corpus striatum — large lesions produce hemiplegia from 
pressure on the internal capsule. 

Optic thalamus — large lesions may produce hemianesthesia 
from pressure upon the posterior limb of the internal capsule, 
and sometimes hemianopia. 

Corpora quadrigemina — hemianopia, nystagmus, and symp- 
toms resulting from pressure on the crura cerebri. 

Crura cerebri — hemiplegia and hemianesthesia on one 
side, and paralysis of the oculo-motor nerve on the other. 

Pons — paralysis of the cranial nerves, and in many cases 
hemiplegia and hemianesthesia on one side, and facial paralysis 
on the other. 

Internal capsule — hemiplegia on the opposite side. 

Medulla — paralysis of the cranial nerves, difficult articu- 
lation, cardiac and respiratory disturbances, vomiting, and 
sometimes hemiplegia. 

Cerebellum (middle lobe) — staggering gait, vomiting, 
vertigo, and marked headache. 

Prognosis. — When the tumor is not gummatous, and is 
not suitable for operative interference, the prognosis is un- 
favorable. The duration is from a few months to several 
years. 



350 DISEASES OF THE NERVOUS SYSTEM. 

Treatment. — Localized cortical growths, which are not 
malignant or syphilitic, are suitable for operative interference. 
In cerebral gumma inunctions of mercury should be employed, 
and mercury and iodide of potassium given by the mouth. In 
other cases the treatment is palliative. Cold applications to 
the head, bromides, antipyrin, and morphia are required to 
relieve pain. 

ABSCESS OF THE BRAIN. 

( Suppurative Encephalitis . ) 

Etiology. — (1) It may be traumatic. (2) It may be se- 
condary to suppurative inflammation of adjacent parts, as 
caries of the temporal bone following otitis media, (3) It 
may be secondary to some distant focus of suppuration, as in 
pulmonary abscess, hepatic abscess, ulcerative endocarditis. 
(4) It may arise without obvious cause. 

Pathology. — The abscess varies in size from a pea to one 
large enough to fill an entire hemisphere. The surrounding 
tissues are hypersemic, oedematous, and more or less infiltrated. 
In the acute form the abscess is diffuse, but in long-standing 
cases the pus is encapsulated by a thick fibrous sac. The 
temporo-sphenoidal lobe and the cerebellum are the most 
frequent seats. Abscesses secondary to distant foci of sup- 
puration are commonly multiple. 

Symptoms. — Abscesses following injury frequently run an 
acute course, and are characterized by high fever, rigors, head- 
ache, delirium, convulsions, vomiting, and coma. 

In chronic cases the general symptoms are headache, irrita- 
bility, mental impairment, vertigo, vomiting, irregular fever, 
stupor, pallor, and loss of flesh and strength. The focal 
phenomena vary with the location of the abscess. Involve- 
ment of the motor area may be attended with convulsions or 
paralysis in one limb ; of the temporo-sphenoidal lobe, with 
deafness, and perhaps aphasia ; of the occipital lobe, with 
hemianopia ; of the cerebellum, with persistent vomiting and 
loss of coordination. 

Diagnosis. Cerebral Tumors. — The history of traumatism 
or of some primary suppurating disease, such as otitis, bron- 






CRETINISM. 351 

chieetasis, empyema, ulcerative endocarditis ; the presence of 
fever, and the absence of choked disk will indicate abscess. 

Acute cases can rarely be distinguished from suppurative 
meningitis. 

Prognosis. — Grave. When the focal symptoms indicate 
involvement of an accessible region like the motor area, 
temporo-sphenoidal lobe, or cerebellum, operative interference 
affords considerable hope of success. 

Treatment. — When the abscess is located in one of the 
regions specified, the skull should be trephined and the pus 
evacuated. In other cases the application of wet cups to the 
neck, of ice-bags to the head, and the internal use of opium, 
bromide of potassium, or of chloral, may temporarily relieve 
the distress. 

CRETINISM. 

Definition. — A congenital affection, characterized by a 
lack of physical development, an abnormal condition of the 
thyroid gland, myxoedema, and idiocy or imbecility. 

Etiology. — Beyond heredity no cause is known. The 
condition is endemic in the Alps and Pyrenees. Sporadic 
cases are also observed in other parts of the world. 

Symptoms. Endemic Cretinism. — The stature is short 
(three or four feet) ; the head is large, flat antero-posteriorly 
and broad laterally ; the eyes are wide apart ; the nose is flat; 
the lips are thick ; the tongue is large and may protrude from 
the mouth ; the chest is narrow ; the belly is prominent ; the 
fingers are short; the genitalia are not developed ; the sub- 
cutaneous tissues, especially at the root of the neck, are 
thickened from mucoid or fatty deposits ; the thyroid gland is 
generally enlarged ; and the mental condition is that of idiocy. 

Sporadic cases present the same features, but the thyroid, 
instead of being larger, is atrophied. 

Congenital conditions presenting to a limited extent the 
phenomena of cretinism are not uncommon, and are termed 
cretinoid. 



352 DISEASES OF THE NERVOUS SYSTEM. 

SPINAL LEPTOMENINGITIS. 

(Spinal Meningitis.) 

Definition. — An inflammation of the spinal pia mater not 
associated with infectious cerebro-spinal meningitis. 

Etiology. — The infectious fevers, exposure to cold and wet, 
traumatism, and tuberculosis are the etiological factors. 

Pathology. Acute Form. — The membranes are opaque, 
thickened, congested, and adherent. The fluid in the arach- 
noid space is increased. In very acute cases there is more or 
less purulent infiltration. The periphery of the cord is al- 
ways involved. 

Chronic Form. — The membranes are very thick and fused 
into one homogeneous fibrous mass. 

Symptoms. Acute Form. — The disease may begin with a 
chill, which is followed by moderate fever. There is intense 
pain in the back radiating along the course of the nerves. 
The back is exquisitely tender. The spinal muscles are rigid 
and contracted, sometimes so much so as to induce opisthot- 
onos. The reflexes are increased. When the exudate is 
sufficient to make considerable pressure on the cord, paralytic 
phenomena develop, such as slight anaesthesia and partial 
paralysis of the extremities. 

There are no cerebral symptoms unless the meninges of the 
brain are involved. 

Diagnosis. Myelitis. — In this aifection there are marked 
paralysis and anaesthesia ; involvement of the bladder and 
rectum ; and the formation of bedsores 

Rheumatism of the Muscles and Fibrous Tissues of the Back. — 
In this condition the joints are involved; the urine is highly 
acid ; the pain does not follow the nerve-trunks ; and the 
symptoms yield to the salicylates. 

Tetanus. — The presence of a wound ; the absence of fever ; 
the early involvement of the jaw; and the absence of exquisite 
tenderness in the back will separate tetanus from meningitis. 

Prognosis. — Extremely grave. Eecovery sometimes fol- 
lows, but rarely without partial paralysis. 

Chronic Leptomeningitis. — Pain in the back ; stiffness of 



CHRONIC SPINAL PACHYMENINGITIS. 353 

muscles; hyperesthesia and paresthesia of the lower ex tremi-. 
ties, but rarely any anaesthesia ; some loss of power ; and 
increased reflexes. 

Treatment. — An ice-bag, leeches, or cups may be applied 
to the spine. Sedatives like chloral, bromides, and morphia 
are usually required. Warm baths relieve the pain and lessen 
the rigidity. Ergot and iodide of potassium are recommended. 

If the acute symptoms subside, iodide of potassium may be 
administered internally ; blisters and mercurial inunctions 
may be applied to the spine, and massage and electricity to 
the affected muscles. 

CHRONIC SPINAL PACHYMENINGITIS. 

(Cervical Hypertrophic Pachymeningitis, Internal 
Pachymeningitis. ) 

Definition. — A chronic inflammatory affection of the dura 
mater, characterized by severe pains in the head, shoulders, 
arms, and loins, followed by paresis, wasting, and anaesthesia. 

Etiology. — Male sex, middle life, prolonged exposure to 
cold, lowered vitality, spinal concussion, alcoholism, and syphilis 
are predisposing factors. It may be secondary to inflammation 
of neighboring structures. 

Pathology. — The membranes are thickened, opaque, and 
adherent ; the vessels are dilated ; and the spinal fluid is in- 
creased. In advanced cases the membranes are glued together 
and form a thick, homogeneous, fibrous mass. The cervical 
region is most commonly affected. The inflammation may 
extend to the cord and peripheral nerves. 

Symptoms. — Sharp pains radiating into the head, shoulders, 
arms, and loins, followed by loss of power, anaesthesia, wast- 
ing, and rigidity, particularly in the upper extremities. When 
the lower part of the cord is involved the same phenomena 
are observed in the legs. The duration of the disease is 
several years. 

Diagnosis. Chronie Poliomyelitis. — The absence of pain 
and of anaesthesia will separate poliomyelitis from pachy- 
meningitis. 
23 



354 DISEASES OF THE NERVOUS SYSTEM. 

Multiple Neuritis. — In this affection the pain is less marked 
in the back and more marked in the extremities, and the nerve- 
trunks are tender on pressure. 

Spinal Irritation. — In this condition the spine is tender at 
certain spots, and there is no radiating pain, anaesthesia, or 
wasting. 

Prognosis. — This depends on the extent and cause. When 
the involvement is slight or is due to syphilis, the prognosis 
should be guardedly favorable. 

Treatment. — Absolute rest, Tonics are often indicated. 
Counter-irritation should be made along the cord by frequent 
blisters or the actual cautery. Morphia, antipyrin, or phena- 
cetin may be required for the relief of pain. Iodide of potas- 
sium may be administered for its absorbent effect, and in 
syphilitic cases it should be given freely in conjunction with 
some mercurial. 

ACUTE MYELITIS. 

Definition. — An acute inflammation of the substance of 
the cord, characterized by marked disturbances of motion, sen- 
sation, and nutrition. 

Varieties. — When only a transverse section is involved 
the condition is termed transverse myelitis. When a large 
vertical section is affected the disease is termed diffuse myelitis. 
When the gray matter is especially involved it is termed central 
myelitis. 

Etiology. — Traumatism; exposure to cold, especially when 
the body is overheated; over-exertion; alcoholism; syphilis; or 
the infectious fevers may induce it. It is sometimes secondary 
to a hemorrhage or a morbid growth in the cord. 

Pathology. — The membranes are usually injected and 
opaque. The substance of the cord is red and soft, and the 
line of demarcation between the gray and white matter is in- 
distinct. In very acute cases the substance of the cord may 
flow out as a reddish, creamy fluid when the membranes are 
cut. Occasionally there are conspicuous hemorrhagic effusions 
(hsemato myelitis). 

Microscopic examination reveals destruction of the nerve- 



ACUTE MYELITIS. 355 

elements, and in their place granular debris, fat-globules, red 
blood -corpuscles, and leucocytes. 

Symptoms. Acute Transverse Myelitis. — Moderate fever 
(101°-103°), loss of appetite, coated tongue, and constipa- 
tion, followed by pain in the back radiating into the limbs. 
With the pain there are often various forms of paresthesia, 
as numbness, tingling, burning, etc The muscles may be the 
seat of tremors or of convulsive seizures. There is frequently 
a sense of painful constriction — "girdle pain" — at the level of 
the disease. Paralysis soon develops, and may become more 
or less complete. The reflexes are generally increased when 
the lesion is above the lumbar enlargement ; but if the latter 
is involved they are lost. The paralyzed muscles are flabby, 
but do not yield the reactions of degeneration ; when, how- 
ever, the reflexes are exaggerated the muscles often become 
rigid and contracted. At first there may be retention of 
urine and feces, but later there is frequently incontinence. 
Anesthesia is more or less complete. Bedsores soon develop 
and add to the distress of the patient. 

Death may result in a few days from extension upward and 
involvement of the respiratory muscles. In many cases life 
is prolonged for several weeks, death finally resulting from 
exhaustion induced by bedsores and cystitis. In rare cases 
there is a spontaneous arrest of the inflammation, and slow 
recovery follows, attended with partial paralysis. 

Acute Central Myelitis — This resembles the former, but the 
trophic disturbances are much more marked and the dura- 
tion is shorter. The disease is characterized by moderate fever 
and its associated phenomena, pain in the back, complete loss 
of power and of sensation, loss of reflexes, incontinence of 
urine and feces, rapid wasting of the muscles, and the early 
development of bedsores. The disease invariably proves 
fatal in from one to two weeks. 

Diagnosis. Acute Poliomyelitis. — In this disease the blad- 
der and rectum are not involved, and there are no sensory 
disturbances. 

Landry's Disease, or Acute Ascending Paralysis. — In this 
affection trophic disturbances are absent ; the bladder and 
rectum are not involved ; and the loss of sensation is slight. 



356 DISEASES OF THE NERVOUS SYSTEM. 

Multiple Neuritis. — The " girdle pain" is absent ; the sphinc- 
ters are not affected ; bedsores are rare ; and pain is more 
marked in the extremities than in the back. 

Meningitis — The girdle pain is absent ; the sphincters are 
not affected ; the irritative phenomena are more marked than 
the paralytic. 

Hemorrhage into the Cord. — The paralysis develops ab- 
ruptly. 

Prognosis. — Always extremely grave. Acute central 
myelitis is invariably fatal. In other cases recovery attended 
with partial paralysis occasionally follows. 

Treatment. — If possible, the patient should be placed on 
a water-bed. To delay the formation of bedsores extreme 
cleauliness is essential. Both in retention and incontinence of 
urine the catheter should be used twice daily. In incontinence 
of urine and feces the discharges should be received on cotton- 
wool or oakum, which should be frequently renewed and the 
parts thoroughly cleansed. In the beginning an ice-bag or 
wet cups may be applied to the spine. Such remedies as ergot, 
belladonna, quinine, and mercury are frequently employed, but 
they seem to exert little influence. If recovery should follow, 
massage, electricity, and strychnia may be employed with the 
hope of restoring power to the paralyzed muscles. 

CHEOMC 3IYELITIS. 

Etiology. — Middle life, continued exposure to cold and 
wet, syphilis, alcoholism, gout, traumatism, and excesses are 
the predisposing factors. 

Pathology. — The membranes are opaque and adherent. 
The whole cord has a grayish color ; it is firmer than normal 
and somewhat contracted. 

Microscopic examination reveals destruction of nerve-ele- 
ments, and their replacement by an overgrowth of connective 
tissue. 

Symptoms. — The disease begins gradually with numbness, 
tingling, or burning in the lower extremities, followed by a loss 
of power and sensation. The reflexes are generally exagger- 
ated. The sphincters soon become involved. The muscles do 






SCLEEOSIS OF THE SPINAL CORD. 357 

not waste until the disease is far advanced. As in other 
organic affections of the cord, there is often a sense of constric- 
tion, or "girdle pain," at the level of the disease. The disease 
progresses very slowly, the duration being from six months to 
ten years. 

Diagnosis. — The diagnosis rests on the gradual develop- 
ment of symptoms indicating a general involvement of the 
cord. 

Treatment. — The patient should be put at rest; tonics 
are often indicated ; counter-irritation to the spine by repeated 
blisters or applications of the actual cautery, often yields good 
results. The frequent use of tepid baths is also beneficial. 
The special remedies which have been recommended are 
arsenic, strychnia, phosphorus, nitrate of silver, mercury, and 
iodide of potassium. When there is a suspicion of syphilis 
the last two remedies should be given a thorough trial. 

SCLEROSIS OF THE SPINAL CORD. 

(Duchenne's Disease.) 

Definition. — A degenerative affection of the spinal cord, 
characterized anatomically by an atrophy of the nerve-elements 
and an overgrowth of connective tissue. 

Etiology. — Middle life, male sex, syphilis, alcoholism, 
mineral poisoning, excesses, and continued exposure to cold 
and wet are the usual causes. 

Locomotor Ataxia. 

(Locomotor Ataxy, Tabes Dorsalis, Posterior Sclerosis.) 

Definition. — A sclerosis affecting the posterior columns 
of the cord, and characterized by incoordination, loss of deep 
reflexes, disturbances of nutrition and of sensation, and various 
ocular phenomena. 

Pathology. — The membranes over the posterior columns 
are often opaque and adherent. The posterior columns have 
a grayish color, and are firm and shrunken. 

Microscopic examination reveals atrophy of the nerve- 
fibres and an overgrowth of connective tissue. Degenerative 



358 DISEASES OF THE NERVOUS SYSTEM. 

changes are frequently observed in the basal ganglia and in 
the peripheral nerves. 

Symptoms. Motor Phenomena. — One of the earliest 
symptoms is loss of coordination. This is first manifested 
by unsteadiness when the patient walks in the dark. When 
he stands erect, with the eyes closed and feet together, he 
staggers and tends to fall (Romberg's symptom). When the 
arms are affected there is inability to perform work requiring 
delicate coordination, such as writing and piano-playing. 
This loss of coordination in the upper extremities becomes 
conspicious when the patient, while his eyes are closed, at- 
tempts to touch the tip of his nose. 

The gait is characteristic ; in walking he raises his feet high, 
throws them forwards, and brings them down forcibly in such 
a way that the whole sole strikes the floor at once. Although 
the patient may be unable to walk or to use his hands with 
precision, there is no actual loss of power. 

Sensory Phenomena. — Pain is rarely absent ; it is sharp and 
lancinating in character, and appears in paroxysms. It usually 
involves the extremities, but sometimes it attacks the stomach 
and is accompanied with obstinate vomiting. The term gastric 
crisis is applied to this phenomenon. 

Crises may occur in other organs, notably the larynx, where 
they are manifested by intense dyspnoea and stridulous breath- 
ing. Various forms of paresthesia are observed, such as 
tingling, numbness, " pins and needles/' and the like. Irregu- 
lar areas of anaesthesia are frequently distributed over the body. 

Reflexes. — The patellar reflex is lost very early in the 
disease. The pupil fails to respond to light while it still 
accommodates for distance (Argyll-Robertson pupil). 

Eye Phenomena. — The most important are diplopia, con- 
tracted pupils, dimness of vision from optic atrophy, and 
paresis of the ocular muscles. 

Trophic Phenomena. — The most curious are the so-called 
arthropathies, which consist of enlargement of the joints, 
associated with serous effusions, atrophy of the heads of the 
bone, erosion of the cartilages, and calcification of the liga- 
ments. These articular changes sometimes lead to luxations. 

Perforating ulcer of the foot is sometimes observed. 



SCLEROSIS OF THE SPINAL CORD. 359 

Other symptoms sometimes observed are : loss of sexual 
power, paralysis of the sphincters, epileptiform seizures, and 
dementia. 

Diseases with which locomotor ataxia may be asso- 
ciated. — Spastic paraplegia, multiple neuritis, paretic demen- 
tia, and chronic poliomyelitis. 

Diagnosis. Multiple Neuritis. — In this affection the 
peripheral nerves are tender; the muscles may yield the 
reactions of degeneration; the pain is not lancinating like 
that of ataxia ; and the Argyll-Robertson pupil is absent. 

Tumor of the Cerebellum. — In this condition the reflexes are 
not abolished, lightning pains are absent, and instead there 
are persistent vomiting, headache, and optic neuritis. 

Gastralgia. — A gastric crisis may be mistaken for gastralgia, 
but the associated phenomena of locomotor ataxia will prevent 
an error in diagnosis. 

Prognosis. — Generally unfavorable, although arrest and 
even improvement are not infrequent. The duration is in- 
definite. 

Treatment. — The patient should be placed under the best 
hygienic conditions. Rest is desirable. In the early stage a 
prolonged voyage may produce excellent results. The diet 
must be nutritious, but easily assimilable. Excesses of all 
kinds must be rigidly prohibited. Tonics are frequently in- 
dicated. When there is a suspicion of syphilis, iodide of 
potassium should be given in full doses. In other cases iodide 
of potassium in small doses, mercury, and arsenic, are the 
most reliable remedies. The following pill may prove 
useful : — 

I$l Sodii arseniat., 

Zinc, phosphid. , aa gr. ij ; 

Hydrarg. iodid. rub., gr. j. — M. 
Ft. in pil. No. xxx. 
Sig. — One, three times daily after meals. 

Counter-irritation to the spine is useful and may be made 
with small blisters or the actual cautery. 

The Pains. — When very intense, morphia will be required ; 
in other cases antipyrin, phenacetin, and cannabis indica arc 
sometimes efficient. 



360 DISEASES OF THE SERVOLS bYtfHStt. 

I£ Antipyrin, £j ; 
Syr. zingiber., f%j ; 

Aquas q. s. ad £§iv. — M. (Germain See.) 
Sig. — A teaspoonful every one to four hours for three to six 
doses. 

The laryngeal crises may be relieved by the inhalation of 
chloroform or amyl nitrite. 

Primary Spastic Paraplegia. 

(Lateral Sclerosis, Antero-lateral Sclerosis.) 

Definition. — A nervous affection probably dependent 
upon sclerosis of the lateral columns, and characterized by 
loss of power, increased reflexes, and a spastic condition of the 
muscles. 

Pathology. — There is probably a sclerosis of the lateral 
columns of the cord. 

Symptoms. — Loss of power is generally the first symptom. 
This begins in the lower extremities and increases very slowly. 
The knee-jerk is exaggerated, and in most cases ankle-clonus 
can be elicited. When put in use the muscles become stiff, or 
spastic, and when the disease is fully developed the gait is 
peculiar. In walking the knees are drawn together, the legs 
drag behind, and the toes catch the ground. 

The muscles do not waste, but rather tend to become hyper- 
trophied from continued reflex stimulation. The sphincters 
are ultimately affected. Sensation is generally undisturbed, 
but subjective phenomena like numbness and tingling may be 
observed. The upper extremities are not often involved, but 
finally loss of power and rigidity may develop in them also. 

Prognosis. — Unfavorable. In rare instances the disease is 
arrested. 

The duration is indefinite. 

Treatment. — The general treatment is the same as in 
locomotor ataxia. For the spasmodic condition of the mus- 
cles, rubbing, warm baths, and the following remedies are 
recommended : bromide of potassium, calabar bean, and bel- 
ladonna. 



SCLEROSIS OF THE SPINAL CORD. 361 

Amyotrophic Lateral Sclerosis. 

Definition. — A nervous affection characterized anatomi- 
cally by a degeneration of the lateral columns and adjacent 
gray matter, and manifested clinically by loss of power, 
wasting, and a spastic condition of the muscles. 

Pathology. — The disease apparently depends upon a 
sclerosis involving mainly the anterior horns of the gray matter 
and the anterolateral columns. 

Symptoms. — Loss of power and wasting, usually beginning 
in the small muscles of the hand, and gradually spreading over 
the entire body. The reflexes are exaggerated. When the 
muscles are put into use, they become more or less rigid, or 
spastic. The degenerative process extends upwards until it 
involves the medulla, when symptoms of bulbar palsy appear. 

Diagnosis. — The spasmodic condition of the muscles will 
distinguish it from pure progressive muscular atrophy. 

Prognosis. — Unfavorable. 

Treatment. — Such remedies as arsenic and iodide of 
potassium are recommended, but they usually prove useless. 
The spastic condition is improved by massage. 

Ataxic Paraplegia. 

Definition. — A sclerotic affection of the posterior and 
lateral columns manifesting symptoms of both locomotor ataxia 
and spastic paraplegia. 

Symptoms. — It resembles spastic paraplegia in the loss of 
power, spastic condition of the muscles, increased reflexes, and 
absence of sensory disturbances ; and locomotor ataxia in the 
distinct loss of coordination. 

Disseminated Cerebro- spinal Sclerosis. 

(Multiple Sclerosis, Insular Sclerosis.) 

Definition. — A chronic nervous disease characterized ana- 
tomically by patches of sclerosis of varying size scattered 
through the brain and cord. 

Etiology. — The causes which lead to other scleroses of the 
cord may induce this disease ; the infectious fevers, however, 



362 DISEASES OF THE NERVOUS SYSTEM. 

are assigned a prominent place in its etiology. It is more 
commonly observed in younger people than is locomotor ataxia 
or lateral sclerosis. 

Patholgy. — Areas of firm, gray, sclerotic tissue, of various 
sizes and shapes, are found through the brain and cord. 

Symptoms. — The spinal symptoms may resemble either 
locomotor ataxia or lateral sclerosis, according as the posterior 
or lateral columns are chiefly affected. The characteristic 
symptoms are loss of power, usually most marked in the legs ; 
increased reflexes: vague pains ; a coarse tremor developed on 
movement (volitional tfymor) ; a slow, hesitating, " scanning" 
speech ; nystagmus — tremor of the eyeballs ; and mental im- 
pairment. Sensory and trophic disturbances are generally 
absent. 

Diagnosis. — Disseminated sclerosis may be mistaken for 
paralysis agitatis, but the latter disease develops in late life; 
the tremor is fine, rarely involves the head, and is not made 
worse by use of the muscles ; and nystagmus is absent. 

Prognosis. — Unfavorable. The duration is indefinite, and 
long remissions with improvement of the symptoms are not 
uncommon. 

Treatment. — The general treatment is the same as that 
for posterior sclerosis. Bromides, hyoscine, hyoscyamine, and 
belladonna have been .recommended for the tremors. 

Hereditary Ataxia. 

(Friedreich's Disease.) 

Definition. — A sclerotic affection of the spinal cord, occur- 
ring in several children of the same family, and characterized 
by symptoms resembling locomotor ataxia. 

Etiology. — The greatest number of cases develop between 
the second and fifteenth years. Some can be traced to heredi- 
tary influence ; in others a cause cannot be ascertained. 

Pathology — Sclerosis of the posterior and lateral columns 
of the cord. 

Symptoms. — Loss of coordination in the arm and legs, 
nystagmus, irregular jerking movements of the hands, loss of 



ACUTE ANTERIOR POLIOMYELITIS. 363 

reflexes, a scarmiDg speech, spinal curvature, equino-varus (heel 
raised and the sole turned in). 

It differs from locomotor ataxia in the absence of sharp 
pains, anaesthesia, the Argyll-Robertson pupil, and in the 
occurrence of irregular movements of the hands, nystagmus, 
scanning speech, and equino-varus. 

Prognosis. — Unfavorable. The duration is many years. 

SYRINGO-MYELIA. 

Definition. — A cavernous condition of the cord associated 
with an overgrowth of the neuroglia surrounding the central 
canal. 

Etiology. — The disease is probably of congenital origin, 
although it may not manifest itself until puberty. 

Symptoms. — Neuralgic pains ; paralysis and wasting of the 
muscles, which ultimately become spastic ; a loss of painful 
and thermic sensation, while tactile sensation is preserved, are 
the chief symptoms. 

Diagnosis. Chronic Poliomyelitis. — In this affection there 
are no sensory disturbances. 

Morvan's Disease. — This disease closely resembles syringo- 
myelia, but tactile sensation is lost and there is a marked 
tendency to painless whitlows. 

Prognosis. — Unfavorable. Duration, six months to two 
years. 

Treatment. — Palliative. 

ACUTE ANTERIOR POLIOMYELITIS. 

(Infantile Paralysis, Atrophic Spinal Paralysis.) 

Definition. — An acute disease, occurring almost exclu- 
sively in young children, characterized anatomically by a de- 
struction of the ganglion-cells in the anterior gray horns of the 
cord, and manifested clinically by abrupt paralysis and rapid 
wasting of certain muscles. 

Etiology. — The greatest number of cases occur within 
the first three years, and the disease is far more common in 
summer than in winter. The sudden onset, the absence of 



364 DISEASES OF THE NERVOUS SYSTEM. 

any known exciting cause, and the fact that it has occurred 
epidemically suggest an infectious origin. 

Pathology. — The sudden onset and wide-spread initial 
paralysis are probably due to intense congestion, and the per- 
manent paralysis and wasting to destruction of the ganglion- 
cells in the anterior gray horns. Microscopic examination in 
recent cases reveals ecchymoses, destruction of ganglion-cells, 
and infiltration of leucocytes. 

Examination long after the development of the paralysis 
reveals an absence or atrophy of the large multipolar cells 
in the gray horns, and in their stead an overgrowth of connec- 
tive tissue. The anterior nerve-roots and muscles also reveal 
degenerative changes. 

Symptoms. — Generally the onset is abrupt ; often the child 
is put to bed in apparent health and in the morning is found 
paralyzed in one or more limbs. In some cases febrile symp- 
toms precede the attack, and more rarely the disease is ushered 
in with a chill, a convulsion, or delirium. 

The paralysis at first may be quite extensive, but more com- 
monly it confines itself to certain groups of muscles in the 
upper and lower extremities. The latter are especially prone to 
suffer ; the affected muscles are relaxed, and the surface is cold 
and often cyanosed. The paralysis is peculiar in its irregular 
distribution and in its tendency to improve spontaneously up to 
a certain limit. There are no sensory disturbances, no involve- 
ment of the bladder and rectum, and no tendency to bedsores. 
The muscles which are permanently affected rapidly waste and 
yield the reactions of degeneration. From contractures of the 
atrophied muscles and contraction of their healthy antagonists, 
various deformities develop. 

Diagnosis. — The abrupt onset will distinguish it from both 
idiopathic muscular atrophy and progressive muscular atrophy. 
The absence of sensory disturbances, bedsores, and paralysis 
of the bladder and rectum will separate it from myelitis. The 
presence of cerebral symptoms, of choreiform or athetoid 
movements in the affected members, and the absence of reac- 
tions of degeneration and of early wasting will separate cere- 
bral paralysis of childhood from acute poliomyelitis. 



PROGRESSIVE MUSCULAR ATROPHY. 365 

Prognosis. — Unless the initial symptoms are very severe, 
the prognosis, as regards life, is good. In all cases some of 
the paralysis disappears. Occasionally the improvement is so 
great that the usefulness of the member is not impaired ; but 
far more frequently the residual paralysis is sufficient to cause 
considerable deformity and disability. 

Treatment. — During the acute stage the child should be 
confined to bed. To relieve the congestion, dry cups may be 
applied to the spine and ergot may be given internally. The 
aifected members should be wrapped in flannel. 

After the lapse of two or three weeks electrical treatment 
should be instituted j the faradic current may be employed 
when it induces contraction of the affected muscles, but when 
it excites no response the galvanic current must be substituted. 
Massage is a very valuable adjunct to the electrical treatment. 
Internally strychnia (gr. T Jo to a child of two years) gradually 
increased is a useful muscular stimulant. Massage and the 
adjustment of mechanical appliances will be required to combat 
deformity from contractures. 

PROGRESSIVE MUSCULAR ATROPHY. 

(Chronic Spinal Muscular Atrophy, Chronic Poliomyelitis.) 

Definition. — A chronic nervous affection, characterized 
anatomically by degeneration of the ganglion-cells of the gray 
matter in the cord, and manifested clinically by loss of power 
and atrophy of corresponding muscles. 

Etiology. — Male sex, middle life, and hereditary tendency 
are the predisposing causes. It sometimes follow prolonged 
emotional excitement, exposure to cold, traumatism, and 
syphilis. 

Pathology. — Microscopic examination of the gray matter 
of the cord reveals atrophy or complete absence of the large 
multipolar cells in the anterior cornua, and an overgrowth of 
connective tissue. The anterior root-fibres are also the seat of 
degenerative changes. In some cases the lateral columns are 
likewise sclerosed (amyotrophic lateral sclerosis). 

Examination of the affected muscles reveals atrophy of the 
fibres, fatty degeneration, an overgrowth of connective tissue, 



366 DISEASES OF THE NERVOUS SYSTEM. 

and an absence of transverse striatum, and instead, longitudi- 
nal striation. 

Symptoms. — Not infrequently prodromal symptoms are 
noted in the parts to be affected, such as pain, coldness, or 
numbness. Soon, loss of power and wasting begin in the 
small muscles of the hand, namely, the thenar and interossei 
muscles. Although one hand is usually affected before the 
other, the disease tends to become symmetrical. Next to the 
hands the muscles of the shoulders and arms slowly waste, ren- 
dering the bony prominences marked ; and so the disease 
advances little by little until the patient is reduced to a mere 
skeleton. The hands assume a characteristic appearance : from 
atrophy of the interossei and contraction of the long extensor and 
flexor muscles they become "claw-like." The wasted mus- 
cles are frequently the seat of fi biliary tremors. The response 
to the galvanic and faradic currents is diminished, but the re- 
actions of degeneration do not develop until the disease is far 
advanced. Although the patient may complain of coldness 
and numbness, sensation is not impaired. The legs are not 
involved until late, and often escape entirely. 

The wasting progresses very slowly, and death may result 
from some intercurrent disease ; if such is not the case, exten- 
sion to the medulla leads to symptoms of bulbar palsy, such as 
indistinct articulation, inability to pucker the lips, difficult 
swallowing, and embarrassed respiration. 

Complications. — It may be associated with lateral sclerosis, 
when it is termed amyotrophic lateral sclerosis. It may lead to 
bulbar palsy. 

Diagnosis. Primary Muscular Atrophy. — This disease 
develops in earlier life, rarely begins in the hand, and the 
hereditary tendency is more marked than in poliomyelitis. 

Prognosis. — Always unfavorable. The duration is indefi- 
nite. 

Treatment. — Good hygiene. Nutritious food. Tonics. 
Gowers claims good results from the hypodermic injection of 
nitrate of strychnia (gr. r J-g- increased to -£$) once daily. 
Massage and electricity yield no results. 



ACUTE ASCENDING PARALYSIS. 367 

BULBAR PARALYSIS. 

(Glosso-labio-laryngeal Paralysis.) 

Definition. — Paralysis of the lips, tongue, pharynx, and 
larynx from destruction of the ganglionic cells of the medulla 
oblongata. 

Etiology. — An acute form is observed which results either 
from hemorrhage or from an acute poliomyelitis of the medulla. 
The chronic form, or progressive bulbar palsy, may result 
from chronic poliomyelitis involving primarily the medulla, 
or from the extension of the degenerative process in paretic 
dementia, amyotrophic lateral sclerosis, progressive muscular 
atrophy, or acute ascending paralysis (Landry's disease). 

Symptoms. — Impairment of speech ; inability to protrude 
the tongue; dribbling of saliva ; difficult swallowing ; choking 
spells from the entrance of food or mucus into the larynx ; 
partial suppression of the voice and measured speaking ; 
fibrillary tremors of the lips and tongue ; loss of reflex action ; 
atrophy of the lips, tongue, and pharynx ; and, finally, difficult 
respiration and disturbed cardiac rhythm. 

Prognosis. — Unfavorable. The acute variety is speedily 
fatal ; the chronic form may last several years. Death may 
result from exhaustion, cardiac failure, or aspiration-pneu- 
monia. 

Treatment. — Electricity, strychnia, and the use of a 
stomach -tube when swallowing becomes difficult. 

ACUTE ASCENDING PARALYSIS. 

(Landry's Disease.) 

Definition. — An acute disease of rare occurrence, char- 
acterized by motor paralysis, beginning in the feet and rapidly 
spreading until it involves the muscles of respiration and deg- 
lutition. 

Etiology. — The causes are unknown. It is usually ob- 
served in young male adults. The abrupt onset, acute course, 
and absence of known cause and of definite lesions have sug- 
gested an infectious origin. 



368 DISEASES OF THE NERVOUS SYSTEM. 

Pathology. — No demonstrable lesions have been dis- 
covered. 

Symptoms. — Febrile symptoms usually usher in the attack. 
The paralysis begins in the legs and involves successively the 
trunk, upper extremities, and muscles of respiration and deg- 
lutition. The reflexes are abolished. The sphincters are 
retentive; sensation is usually normal, but there may be 
paresthesia or some anaesthesia ; the muscles are relaxed, but 
do not waste or yield the reactions of degeneration. 

Diagnosis. Acute Myelitis. — Anaesthesia, wasting, reactions 
of degeneration, and early involvement of the sphincters will 
serve to distinguish myelitis from acute ascending paralysis. 

Multiple neuritis will be separated from Landry's disease by 
the marked sensory disturbances in the former. 

Prognosis. — Unfavorable. The vast majority of cases ter- 
minate fatally in the course of a few days. Occasionally there 
is a spontaneous arrest, and a gradual restoration to health. 

Treatment. — Cups to the spine and electricity to the 
affected muscles have been employed with indifferent results. 

CAISSON DISEASE. 

(Divers' Paralysis.) 

Definition. — A condition observed in divers and others 
subjected to increased atmospheric pressure, and characterized 
by motor and sensory paralysis, particularly of the lower ex- 
tremities. 

Etiology. — A pressure of more than two atmospheres is 
required to produce the paralysis ; and the time elapsing before 
its appearance lessens as the pressure increases. 

Pathology. — The symptoms have been ascribed to the 
liberation in the nerve-centres of gases which have been 
absorbed by the blood during exposure to the high pressure. 
Ecchymoses and irregular fissures have been discovered in 
the cord. 

Symptoms. — The condition may manifest itself immediately 
on reaching the surface or after the lapse of several hours. 
The most important phenomena are pains in the joints fol- 
lowed by motor and sensory paralysis in the lower extremities. 



IDIOPATHIC MUSCULAR ATROPHY. 369 

The bladder and rectum are sometimes involved. Occasion- 
ally the paralysis takes the form of a hemiplegia instead of a 
paraplegia. In severe cases coma develops and death follows 
in a few hours. Generally, however, the symptoms gradually 
subside and the power is fully restored in the course of a few 
days or a few weeks. 

Treatment. — As a preventive measure the transition from 
high to low pressure should be accomplished gradually. 
Marked cases should be treated as acute myelitis. 

IDIOPATHIC MUSCULAR ATROPHY. 

(Muscular Dystrophy, Myopathic Atrophy.) 

Definition. — An atrophic condition of the muscles de- 
veloping in early life and not dependent upon any lesion in 
the nervous system. 

Etiology. — The disease usually manifests itself before 
puberty. It is more common in males than in females. It 
is frequently transmitted from generation to generation, and 
several members of the same family may be similarly affected. 

Pathology. — No lesion in the cord or nerves is observed. 
Gowers regards the disease as of developmental origin. Micro- 
scopic examination of the muscles reveals atrophy of their fibres 
and an unnatural amount of fat and connective tissue. When 
the latter elements are considerably increased, a pseudo-hyper- 
trophy results (pseudo-muscular hypertrophy). 

Symptoms. — The muscles, especially those of the face, 
shoulders, thighs, buttocks, and calves, lose power and waste. 
Fibrillary twitchings are sometimes noted. The reactions of 
degeneration are present. 

Diagnosis. Chronic Poliomyelitis. — This disease develops 
later in life without marked hereditary tendency, and nearly 
always begins in the small muscles of the hands — parts which 
are rarely affected in idiopathic atrophy. 

Multiple Neuritis. — The history, distribution of the palsy, 
and the sensory phenomena will serve to distinguish multiple 
neuritis. 

Prognosis. — Unfavorable. The disease is incurable, but 
of slow progress. 
24 



370 DISEASES OF THE NERVOUS SYSTEM. 

PSEUDOHYPERTROPHIC PARALYSIS. 

(Pseudo-muscular Hypertrophy, Lipomatous Muscular Atrophy.) 

Definition. — A disease of childhood, characterized by 
paralysis depending upon degeneration of the muscles, which, 
however, become enlarged from a deposition of fat and con- 
nective tissue. 

Etiology. — Male sex, childhood, and an hereditary tend- 
ency are the only known predisposing causes. Several cases 
have frequently been observed in the same family. 

Pathology. — The disease is allied to idiopathic muscular 
atrophy, with which it is frequently associated. Since no 
lesions are observed in the cord or peripheral nerves it is to be 
regarded as a primary affection of the muscles. Microscopic 
examination reveals an excessive amount of fat and connective 
tissue between the muscle-fibres, the latter being atrophied and 
more or less degenerated. 

Symptoms. — The first symptom to attract attention is weak- 
ness of the muscles ; the child is awkward, stumbles, and in 
walking seeks support. As the paralysis increases, the mus- 
cles, particularly those of the calf, thigh, buttock, and back, 
enlarge. The upper extremities are less frequently affected. 
When the child assumes the erect posture the feet are wide 
apart, the belly protrudes, and the spinal column shows a 
marked curvature with the convexity forward. The manner 
of rising from the recumbent position is characteristic : He 
straightens himself either by grasping the knees, or by resting 
the hands on the floor in front him, extending the legs, and 
pushing the body backwards. 

Although the response of the muscles to electrical currents is 
less pronounced, the reactions of degeneration are not present. 
The knee-jerk is lessened or abolished. There are no mental 
or sensory disturbances. 

In the course of a few years, the paralysis becomes so marked 
that the patient is unable to leave his bed ; the enlargement 
of the muscles is followed by atrophy ; and finally death 
results from some intercurrent disease, or inflammation of the 
lungs induced by the weakened respiratory power. 



NEURALGIA. 371 

Prognosis . — A bsol utely u n fa v o rab] e. 

Treatment. — Remedies generally prove useless. Graduated 
exercise, massage, electricity, and hypodermics of strychnia 
may be employed with the hope of staying the progress of the 
disease. 

NEURALGIA. 

Definition. — Paroxysmal pain radiating along the course 
of a nerve-trunk. 

Etiology. — Heredity, female sex, nervous temperament, 
excesses, overwork, and nervous exhaustion are general pre- 
disposing factors. It is frequently an expression of anaemia. 
It may result from the action of some toxic agent in the blood ; 
thus it is common in malaria, rheumatism, gout, syphilis, and 
chronic lead-poisoning. It may be caused by reflex irritation ; 
thus a trifacial neuralgia may depend on caries of the teeth or 
eye-strain. In some cases neuralgia results from organic dis- 
ease of the nerve-centre ; thus obstinate trifacial neuralgia 
may be dependent upon some degeneration or tumor of the 
Gasserian ganglion. 

Exposure to cold and wet frequently acts as an exciting 
cause in susceptible people. 

Pathology. — The pathological condition upon which neu- 
ralgia depends is unknown. In many cases, no doubt, it is a 
manifestation of neuritis. 

Symptoms. — Certain prodromes frequently give warning of 
an approaching attack ; these are chilliness, depression of spirits, 
and perhaps tingling in the part to be affected. The chief 
symptom is intense pain, which is usually of a sharp, stabbing 
character. The area supplied by the affected nerve is gener- 
ally hypersesthetic, and palpation detects spots of exquisite 
tenderness where the nerve makes its exit through a bony 
canal or fibrous sheath ; the latter have been termed Yalliex's 
points. In some cases the pain is attended with severe clonic 
or tonic spasms of the muscles. Inspection of the part usually 
reveals negative results, but occasionally distinct swelling or 
an outbreak of herpes is observed. 

The attack lasts from a few minutes to many hours, and its 



372 DISEASES OF THE NERVOUS SYSTEM. 

subsidence may be marked by the passage of a large amount 
of pale urine. The interval between the paroxysms varies in 
different eases ; it is frequently several weeks or months. It 
is noteworthy that the attacks often recur at regular intervals. 

Trifacial Neuralgia {Tic Douloureux, Prosopalgia?) — In this 
variety the pain involves one or more branches of the trifacial 
nerve. The tender points correspond to the supra-orbital, 
infra-orbital, and mental foramina. Violent spasms of the 
muscles are frequently observed. In long-standing cases the 
hair on the affected side may become coarse and bleached. 
Trifacial neuralgia is frequently reflex, being dependent upon 
caries of the teeth, eye-strain, nasal disease, or some distant 
centre of irritation. 

Intercostal Neuralgia. — In this variety the pain follows the 
course of the intercostal nerves. It is frequently associated 
with an eruption of herpes zoster. Spots of tenderness may be 
detected near the vertebral columns, in the middle of the nerve, 
and near the sternum. The frequent dependence of intercostal 
neuralgia upon spinal caries or thoracic aneurism must not be 
forgotten. 

Occipital neuralgia involves the upper cervical nerves. A 
spot of tenderness may be discovered midway between the 
mastoid process and the upper cervical vertebrae. This form 
of neuralgia may be an expression of spinal caries. 

Sciatica has been described elsewhere. 

Diagnosis. Neuritis. — The continuous pain, the tender- 
ness along the entire nerve, the presence of paresthesia, anaes- 
thesia, paresis, and wasting will serve to distinguish neuritis 
from neuralgia. 

The lightning-pains of locomotor ataxia must not be mis- 
taken for neuralgia. The abolished patellar reflex, the loss of 
coordination, and the Argyll-Robertson pupil in the former 
will indicate the diagnosis. 

Prognosis. — For the attack the prognosis is good ; for per- 
manent cure, it must be guarded. When the cause can be 
removed the prognosis is favorable. 

Treatment. The Attach. — The patient should be kept in 
a quiet, cool, well-ventilated room. Local applications are 
useful ; hot cloths, stimulating liniments, an ointment of 



NEURALGIA. 373 

aconitia, a small blister, or a hypodermic injection of cocaine, 
chloroform, or morphia and atropia may be employed. One 
of the following applications will prove serviceable : — 

J$l Aconitia?, gr. iv ; 
Veratriae, gr. xv ; 
Glycerine, 31J ; 

Cerati, ^vj.— M. (Da Costa.) 
Sig. — To be rubbed over the parts. Do not apply to any abrasion 
of the skin. 

Or— 

]£. Chloral, hydrat., 

Pulv. camphor., aa ^ss. — M. 
Sig.— Apply with a camel's hair brush. 

Internally, antipyrin, phenacetin, cannabis indica, bromide of 
potassium, butyl chloral, and exalgine are efficient remedies. 
Morphia is sometimes required, but the danger of inducing the 
habit should always be borne in mind. 

Ihe Interval. — Careful search should be made for an exciting 
cause, which, if found, must be removed. The teeth, eyes, 
nose, gastro-intestinal tract, urine, and blood should be care- 
fully examined. 

In anaemia, iron aud arsenic are indicated ; in syphilis, 
iodide of potassium ; in rheumatism, salicylate of sodium or 
iodide of potassium ; in malaria, quinine and arsenic; in gout 
colchicum and lithium ; in lead-poisoning, iodide of potassium. 

Tonics like iron, quinine, strychnia, cod-liver oil, and phos- 
phorus are frequently indicated. Among the special reme- 
dies may be mentioned arsenic, velerian, hyoscyamus, aconitia, 
gelsemium, cannabis indica, oxide of zinc, nitro-glycerin, xmd 
asafoetida. The following pill, devised by Dr. S. D. Gross, is 
often very useful : — 

fy. Quinin. sulph., 3J 

Morphin. sulph., 

Acid, arseniosi, aa gr. iss ; 

Ext. aconiti, gr. xv ; 

Strychnin, sulph., gr. j.— M. 
Ft. in pil. No. xxx. 
Sig.— One, thrice daily. 

Local treatment in the interval may accomplish much. 
Electricity, acupuncture, or repeated blisters may be employed. 



374 DISEASES OF THE NERVOUS SYSTEM. 

In obstinate cases surgical interference may be required to 
secure relief. Three operations have been performed : Nerve- 
stretching ; neurotomy, or section of the nerve ; and neurec- 
tomy, or removal of a portion of the nerve. 

MIGRAINE. 

(Hemicrania, Megrim, Sick-headache.) 

Definition. — Paroxysmal circumscribed headache asso- 
ciated with visual, vaso-motor, and gastric disturbances. 

Etiology. — It is frequently hereditary. It is more com- 
mon in women than in men. It usually develops in early life. 
Anaemia, gastric disturbances, eye-strain, menstrual disorders, 
overwork, and prolonged emotional excitement predispose to it. 

Pathology. — Unknown. There is a growing tendency to 
regard it as a sensory epilepsy. 

Symptoms. — The attack is often preceded by malaise, rest- 
lessness, and diminished vision. The pain is sharp and 
stabbing and frequently limited to the temporo-frontal region 
of one side. The surface is extremely hypersesthetic, but the 
tender spots noted in trifacial neuralgia are absent. The 
patient is very sensitive to light and sound, and during the 
attack usually confines herself to a darkened room. Nausea 
and vomiting are frequently present. In some cases the tem- 
poral artery is contracted, the face is pale, and the pupil large ; 
in others the artery is dilated, the face is flushed, and the 
pupil small. The duration of the attacks varies from a few 
hours to several days. In the intervals, which are often of 
definite duration, the patient may be quite well. 

Less frequent symptoms are vertigo, hallucinations of sight, 
cramps of the facial muscles, tingling or numbness in one 
hand, partial aphasia, and paresis of the ocular muscles. 

Prognosis. — Perfect cure is rare, but the severity and fre- 
quency of the seizures may be considerably lessened by treat- 
ment. 

Treatment. The Attack. — Rest in a darkened, quiet, and 
well-ventilated room ; anti pyrin, caffeine, bromide of potas- 
sium, salol, and morphia with atropia are useful remedies. 



■ 



HEADACHE. 375 

I£ Antipyrin, 3j ; 

Syr. aurant. cort., f^j ; 
Aquse, q. s. ad f.^iij.— M. 
Sig. — A tablespoonful every two hours. 

Or- 

I£ Caffein. citrat., g'r. xij ; 

Phenacetin, gr. xviij ; 

Sodii bromid., 3j. — M. 
Ft. in chart. No. vi. 
Sig.— One powder every hour. 

Or— 

# Salol, 3j ; 

Caffein. citrat., 
Phenacetin, aagr. xviij. — M. 
Ft. in chart. No. vi. 
Sig. — One every two hours. 

The Interval. — Careful search should be made for some ex- 
citing cause, and when found, removed if possible. The habits 
of the patient must be regulated. Overwork and the use of 
alcohol, strong tea and coffee must be interdicted. Systematic 
exercise and frequent bathing followed by friction are valuable 
adjuncts. The diet must be adapted to the condition of the 
stomach and the needs of the system, Internally, arsenic, 
iodide of potassium, bromide of potassium, valerianate of zinc, 
and cannabis indica are the most reliable remedies. Cannabis 
indica is often very efficient, and a quarter to half a grain of 
the extract may be given for a prolonged period. Little 
recommends : — 

1$l Sodii arseniat., gr. ij ; 

Ext. cannabis indicse, gr. iv ; 

Ext. belladonna?, gr. viij.— M. 
Ft. in pil. No. xxiv. 
Sig. — One, twice daily. 

HEADACHE. 

(Cephalalgia.) 

Definition. — Pain in the head generally resulting from a 
disturbance of the cerebral circulation, a perverted condition 
of the blood, reflex irritation, or pressure on the brain by in- 
flammatory exudate, depressed bone, or a tumor. 



376 DISEASES OF THE NERVOUS SYSTEM. 

Organic Headache. — This form is observed in meningitis, 
cerebral tumor, abscess, softening, etc., and may be recognized 
by its persistence and by the associated evidences of organic- 
cerebral disease, such as optic neuritis, mental aberration, 
paralysis, especially of the facial muscles, and vomiting 
arising independently of other gastric symptoms. 

Under this head is included the headache of syphilis, which 
may be diagnosed by the history ; by the other evidences of 
syphilis ; by its frequent association with somnolence ; and 
by the effect of iodide of potassium. 

Headache of Cerebral Hypersemia. — Active cerebral con- 
gestion usually results from prolonged mental work, fever, 
or exposure to the sun. Toxic and reflex headaches are often 
directly due to active cerebral congestion, but these will be 
discussed later. 

Passive cerebral congestion may result from obstruction to 
the return of blood from the brain, as by a tumor of the neck, 
or cardiac disease. It is also common in elderly people from 
a relaxed condition of the vessels. 

In cerebral congestion the headache is of a throbbing or 
bursting character ; the head is hot ; the face flushed ; the 
eye-ground injected ; and the distress is increased by lowering 
the head. 

The exciting cause must be determined by the history and 
by a careful examination of the various organs, especially the 
heart. 

Headache Of Cerebral Anaemia.— This is frequently de- 
pendent upon general anaemia. It is also common in neuras- 
thenia resulting from overwork, prolonged emotional excite- 
ment, excesses, etc. More rarely it is dependent upon aortic 
stenosis. 

In cerebral anaemia the pain is frequently vertical ; it is not 
throbbing, but it is described as a sensation of weight or gnaw- 
ing ; the extremities are cold ; the face and eye-grounds are 
pale ; the mind is depressed ; fainting spells are often present ; 
lowering the head and the inhalation of nitrite of amyl relieve 
the pain. 

Reflex Headache. — Headache is often due to eye-strain re- 
sulting from refraction errors, and in obstinate cases a careful 



HEADACHE. 377 

examination of the eyes should always be made. Headache 
of this origin is frequently a browache, and may be associated 
with restlessness, vomiting, and insomnia. It is induced or 
aggravated by prolonged use of the eyes. 

Ovarian or uterine diseases often produce a reflex headache. 
It is usually located at the vertex, and is relieved by pressure 
of the hand. 

Gastric irritation is responsible for many headaches; the 
latter are invariably relieved by vomiting, and are usually 
associated with other evidences of stomachic disorder. 

Xasal catarrh may induce persistent headache, which is 
generally confined to the forehead, temples, or vertex, and is 
aggravated by exacerbations of the catarrah. The pain is 
often associated with tenderness of the inner wall of the orbit, 
and is increased by irritating the nasal mucous membrane 
with a probe. 

Toxsemic Headache. — A persistent headache often results 
from Bright' s disease, and is urcemic in origin. It may be 
recognized by the high arterial tension and by the albumin 
and casts in the urine. A urinary analysis should be made in 
all cases of persistent headache. 

Gout or lithwmia produces an intractable headache which is 
associated with vertigo, great irritability of temper, and a 
" brick-dust" deposit in the urine. 

Chronic malarial poisoning may manifest itself in a head- 
ache which is usually confined to the supraorbital region. It 
is apt to recur at regular intervals, is often associated with 
tenderness over the supraorbital nerve, and is only relieved 
by large doses of quinine. 

A headache of rheumatic origin sometimes develops in those 
subject to rheumatism. It is frequently excited by exposure 
or a sudden change of temperature. It usually affects the 
aponeurosis of the occipito-frontalis and temporal muscles, is 
increased by wrinkling the forehead and forcibly moving the 
jaws, and is associated with tenderness of the scalp. 

Alcoholism is often associated with headache. In acute 
alcoholism, the headache probably results from cerebral hyper- 
emia ; in chronic alcoholism it is often due to a low grade of 



378 DISEASES OF THE NERVOUS SYSTEM. 

Among other headaches of toxic origin may be mentioned 
those due to constipation, lead-poisoning, diabetes, infectious 
fevers, and absorption of foul gases. 

Hysterical Headache. — In hysteria there is often a per- 
sistent headache, which grows worse at the menstrual periods, 
and which improves under pleasurable excitement. It may be 
diffuse, but frequently it is localized, and is described as 
resembling the effect which would be produced by a nail being 
driven into the head ; hence it has been termed clavus. 

Diagnosis. — Headache must be distinguished from mi- 
graine. In the latter there are usually prodromal symptoms, 
disturbances of vision, pupillary changes, and the pain is fre- 
quently confined to one side of the head. 

Headache in the region of the orbit may be mistaken for 
acute glaucoma, but in the latter condition the eye is inflamed ; 
the cornea is hazy ; the pupil is sluggish ; vision is impaired ; 
and on palpation the affected eyeball is found to be harder 
than its fellow. 

Treatment. — In the interval between the attacks careful 
search should be made for the cause, which, if possible, must 
be removed. In the reflex headache of eye-strain the ad- 
justment of proper glasses is often all that is required. In 
gastric headache, the associated catarrh of the stomach must be 
treated by a light diet and the use of such remedies as bismuth 
and nitrate of silver. In the headache of anaemia, a nutritious 
diet, with iron, arsenic, and other tonics will be required. In 
headaches of ursemic origin, a milk diet with measures cal- 
culated to increase the action of the skin, bowels, and kidneys, 
will often afford considerable relief. In malarial headache 
quinine in large doses with arsenic will effect a cure. 

The Attack. — In headache dependent upon gastric acidity, 
after unloading the stomach with a non-irritating emetic, 
bromides with antacids will prove useful, thus : — 

fy Sodii bromid., gij ; 

Spt. ammon. aromat., f^ij ; 
Aquae q. s. ad f^iij.— M. 
Sig. — A tablespoonful every hour or two. 

In headache of acute cerebral congestion the feet should be 
soaked for ten or fifteen minutes in very hot water ; an ice- 



NEURITIS. 379 

bag placed on the head ; and some sedative like the following 
administered : — 

T$l Phenacetin, £j ; 

Sodii bromid., £ss. — M. 
Ft. in chart No. xii. 
Sig. — One powder every hour or two until relieved. 

When the attack is very severe, aconite (gtt. j-ij) may be 
given every hour or two. 

In cerebral ansemia good temporarily follows the use of 
antipyrin or phenacetin, especially in combination with caffeine, 
thus : — 

$. Phenacetin, £j ; 

Caffein. citrat., gr. xxiv.— M. 
Ft. in chart No. xii. 
Sig. — One as required. 

In rheumatic headache salol is very useful ; it may be com- 
bined with antipyrin : — 

J$l Salol, £ss ; 

Antipyrin, ^j. — M. 
Ft. in chart No. x. 
Sig. — One every hour or two until relieved. 

In ursemic headache the diet should be restricted to milk, 
action of the bowels secured by a saline draught, and diuresis 
encouraged by digitalis, caffeine, or the vegetable salts of po- 
tassium : — 

1$l Potass, citrat., gij ; 
Spt. juniperi, f%vj ; 
iEther. nitros., f^ij ; 
Infus. scoparii, fjjvj. — M. (Day.) 
A wineglassful, thrice daily. 

NEURITIS. 

Definition. — Inflammation of nerves. 

Etiology. — (1) It may result from traumatism — blows, 
wounds, or compression. (2) It may be due to exposure to 
cold and wet. (3) It may be secondary to inflammation of 
adjacent structures. (4) It may be secondary to rheumatism, 
gout, syphilis, or one of the infectious fevers. 



380 DISEASES OF THE NERVOUS SYSTEM. 

Pathology. — The sheath, interstitial connective tissue, or 
fibres may be independently affected, but as a rule, all parts of 
the nerve are involved. When the process is acute the nerve 
is red and swollen, and microscopic examination reveals an 
infiltration of leucocytes, with more or less granular degenera- 
tion of the fibres. 

In chronic neuritis the nerve-trunk is gray, shrivelled, and 
hard, and microscopic examination shows an overgrowth of 
connective tissue and granular degeneration of fibres. 

Symptoms of Acute Neuritis. — There are three sets of 
phenomena — sensory, motor, and trophic. 

Sensory Symptoms, — There is severe pain following the 
course of the affected nerve, which is tender to the touch. The 
pain is often associated with various manifestations of pares- 
thesia, such as burning, numbness, tingling, and the like. The 
part is at first hyperaesthetic, but later it is more or less anaes- 
thetic. 

Motor Symptoms. — Muscular power is impaired ; there may 
be fibrillar tremors ; and the reflexes are diminished or lost. 

Trophic Symptoms. — An eruption of herpes sometimes fol- 
lows the affected nerves. The skin may become glossy and 
the nails lustreless and brittle. In advanced cases there are 
wasting of muscles and impaired electro-contractility. Occa- 
sionally effusion into the joints is observed. 

In sonle cases there may be febrile symptoms. 

Chronic neuritis is characterized by pain, anaesthesia, paresis, 
atrophy and contracture of the muscles, reactions of degen- 
eration, " glossy skin," and thickening and brittleness of the 
nails. 

Diagnosis. — Neuritis may be mistaken for neuralgia ; but 
in the latter the pain is paroxysmal and is unassociated with 
tenderness along the course of the nerve, paresthesia, anaes- 
thesia, paresis, and changes in the electro- contractility. 

Prognosis. — In acute cases the prognosis is guardedly 
favorable ; the duration is from a few days to several weeks. 
In chronic neuritis, after the development of marked trophic 
changes, the prognosis is grave. 

Treatment. — The cause should be ascertained and, if pos- 
sible, removed. In rheumatism, alkalies and salicylates are 



MULTIPLE NEUKITIS. 381 

indicated. In syphilis, iodide of potassium should be admin- 
istered in large doses. The part should be put at rest. 
For the pain, sedative lotions (lead-water and laudanum), 
warm fomentations, or small blisters may be applied to the 
affected parts, and morphia administered hypodermically. 
When morphia is contra-indicated, salicylate of sodium or 
phenacetin may be employed in its stead. After the sub- 
sidence of acute symptoms, iodide of potassium may be given 
for its absorbent effect and small blisters applied locally. 
Restoration of power will be assisted by massage and elec- 
tricity, and by the administration of strychnia, internally or 
hypodermically. 

MULTIPLE NEURITIS, 

Definition. — Inflammation of several nerve-trunks, re- 
sulting from a general cause, and characterized by pain, 
paresthesia, anaesthesia, paresis, and muscular atrophy. 

Etiology. — Alcoholism, syphilis, rheumatism, the infec- 
tious fevers, exposure to cold and wet, and mineral poisoning 
are common causes. In the Orient, multiple neuritis occurs 
as an endemic disease (Kakke or Beri-beri), which is probably 
microbic in origin. 

Symptoms. — The acute form is characterized by a chill fol- 
lowed by moderate fever (102°-103°), headache, pain in the 
back, malaise, coated tongue, loss of appetite, constipation, 
febrile urine, and the following local phenomena : Pain, numb- 
ness, and tingling in the affected limbs; loss of power, espe- 
cially in the legs and extensor muscles; abolition of the 
reflexes ; atrophy of the muscles ; more or less anaesthesia ; 
and tenderness over the nerve-trunks. 

Chronic Form. — Febrile symptoms are absent and the dis- 
ease is manifested by pains in the limbs, hyperesthesia, pares- 
thesia, irregular areas of anesthesia, loss' of power, abolition 
of the deep reflexes, tenderness over the nerve-trunks, wasting 
of the muscles, impaired electrical contractility, and cedema of 
the hands and feet. 

Complications. — Delirium, delusions, and hallucinations 
are not uncommon, especially in the alcoholic variety. The 
disease is sometimes associated witli locomotor ataxia. 



382 DISEASES OF THE NERVOUS SYSTEM. 

Diagnosis. Locomotor Ataxia. — The absence of the light- 
ning-pains, girdle sensation, Argyll-Robertson pupil, and the 
presence of paralysis, wasting, and neural tenderness will serve 
to distinguish multiple neuritis from locomotor ataxia. 

Prognosis. — Guardedly favorable. Acute neuritis some- 
times proves fatal from involvement of the respiratory mus- 
cles. In chronic cases of long duration the outlook is not 
hopeful. 

Treatment. — Acute cases should be kept at absolute rest. 
For the relief of pain hot fomentations, lead-water and lauda- 
num, and rubefacient liniments may be applied to the affected 
limbs ; and morphia, antipyrin, phenacetin, or salicylic acid 
administered internally. After acute symptoms have sub- 
sided, massage, electricity, and Swedish movements should be 
employed to secure a return of power. An ointment of 
mercury and belladonna may be used for its absorbent and 
anodyne effect. Strychnia hypodermically is an invaluable 
muscular tonic. Rigidity is best relieved by manipulation 
and the frequent use of warm baths. In syphilitic cases em- 
ploy mercurial inunctions and iodide of potassium. 

SCIATICA. 

Definition. — Pain along the sciatic nerve, usually resulting 
from neuritis. 

Etiology. — Male sex, middle life, gout, rheumatism, and 
syphilis are predisposing causes. Exposure to cold and wet 
is the common exciting cause. Very rarely sciatica is a sec- 
ondary condition resulting from the presence of an intra-pelvic 
growth or from caries of the bone in joint disease. 

Symptoms. — The disease may begin abruptly or gradually, 
and is characterized by a sharp shooting pain running down 
the back of the thigh. Movement of the limb intensifies the 
suffering. The pain may be uniformly distributed along the 
course of the nerve, but not infrequently there are certain 
spots where it is more intense. Subjective sensations, such 
as tingling and numbness, are often noted. The nerve may 
be extremely sensitive to touch. The symptoms grow worse 
at night and on the approach of stormy weather. The dura- 



FACIAL PARALYSIS. 383 

tion of the attack varies from a few days to several months. 
In long-standing cases the muscles become atrophied and rigid. 

Diagnosis. Goxalgia. — In this affection the pain is most 
marked in the hip- and knee-joints ; pressure over the tro- 
chanter elicits pain ; and the nerve is not tender to the touch. 

Prognosis. — Recovery follows in the majority of cases 
when treatment is instituted early and is persistently carried 
out. In some cases relapses occur frequently, and finally the 
pain becomes more or less continuous. 

Treatment. — In the acute stage rest is essential. Hot 
fomentations or linear blisters may be applied along the 
course of the nerve. Deep injections of morphia, antipyrin, 
or cocaine may be required to relieve the pain. In rheumatic 
cases full doses of the salicylate of sodium are very useful. 
In chronic cases prolonged rest is desirable. Counter-irritation 
should be made by frequent small blisters, by the actual cautery, 
or by acupuncture. Deep injections along the course of the 
nerve give much relief, and one of the following remedies 
may be so employed : morphia and atropia, cocaine, antipyrin, 
or plain water. Electricity sometimes does good. Internally 
iodide of potassium in small doses is useful ; in syphilitic 
cases it should be given in large doses. The following com- 
bination is also efficient : — 

^ Tinct. aconiti rad., 
Tinct. colchici sem., 
Tinct. belladonna, 

Tinct. cimicifugse, aa f^ij. — M. (Metcalf.) 
Sig. — Twelve drops every four to eight hours. 

FACIAL PARALYSIS. 

(Bell's Palsy.) 

Etiology. — Paralysis of one side of the face may result : 

(1) From a tumor, clot or abscess involving the facial centre 
on the cortex of the brain or the nucleus of the facial nerve ; 

(2) from the pressure of inflammatory exudate on the nerve- 
trunk between the brain and the skull ; (3) from paralysis of 
the nerve within the petrous portion of the temporal bone, 
excited by a fracture, or by an extension of inflammation of 



384 DISEASES OF THE NERVOUS SYSTEM. 

the middle ear ; (4) from inflammation of the peripheral fila- 
ments, excited by exposure, injury, rheumatism, or one of the 
infectious fevers. 

Symptoms. — The side affected is expressionless ; the natural 
lines are obliterated ; the angle of the mouth droops ; the eye 
cannot be closed ; tears flow over the cheek ; and speech is 
affected from an inability to pronounce the labials. When 
the patient attempts to laugh or whistle, the absence of move- 
ment on the affected side beeomes still more conspicuous. In 
peripheral neuritis the reflexes are abolished ; and when the 
nerve is involved in the temporal bone there may be a loss of 
taste in the anterior part of the tongue. 

Diagnosis. — When the lesion is in the brain the paralysis 
is rarely complete, the upper part of the face usually escaping; 
neighboring cranial nerves are frequently affected ; and other 
evidences of organic brain disease are generally present. 

When the nerve is involved within the Fallopian canal 
there is often a loss of taste in the anterior part of the tongue, 
and some disturbance of hearing — deafness or perhaps hyper- 
sensitiveness to sound. 

In peripheral neuritis the history, the completeness of the 
paralysis, and the absence of reflexes will assist in the recog- 
nition of the lesion. 

Prognosis. — The prognosis will vary with the cause. It 
should be guardedly favorable when the paralysis is due to 
peripheral neuritis. 

Treatment. — The cause should be ascertained, and if pos- 
sible, removed. In paralysis of centric origin little can be 
done, except in syphilitic cases, In middle-ear disease reme- 
dies should be directed to that organ. When paralysis results 
from inflammation of the peripheral filaments of the facial 
nerve, blisters should be applied near the stylo-mastoid fora- 
men, and as it often appears to be an expression of rheumatism, 
salicylates may be given internally. Later, a course of iodide 
of potassium will be useful, and restoration of power may be 
materially assisted by massage, electricity, and local injections 
of strychnia. 



EPILEPSY. 885 

EPILEPSY. 

(Idiopathic Epilepsy, Falling Sickness.) 

Definition. — A chronic disease of the nervous system, 
characterized by paroxysms of unconsciousness which are 
usually associated with general convulsions. 

Etiology. — Heredity predisposes, and the ancestral disease 
may not have been epilepsy but insanity, hysteria, or another 
neurosis. It generally begins before puberty, and very rarely 
after the twenty-fifth year. All causes which impair the 
health and exhaust the nervous system exert a predisposing 
influence. The reflex convulsions of children resulting from 
gastric irritation, worms, etc., if long continued may induce 
chronic epilepsy. In these cases, although the exciting cause 
has been removed, the habit of spontaneous motor discharge, 
through constant repetition, is established, and may continue 
through life. In those subject to convulsions, overwork, gas- 
tric irritation, or excitement may precipitate an attack. 

Pathology. — No demonstrable causal lesions are detected. 
The disease apparently depends upon an instability of the motor 
centres, so that from trivial exciting causes violent discharges 
occur from time to time. 

Symptoms. Grand Mai. — The seizure is often preceded by 
a peculiar sensation termed au aura, beginning in a finger or 
toe and rising until it involves the head, when the patient gives 
a shrill scream and falls to the floor unconscious. At first the 
face is ])ale, the pupils contracted, and the body thrown into a 
tonic spasm in which the head is retracted and rotated, the 
limbs forcibly extended, and the thumbs turned into the palms 
and firmly clenched by the flexed fingers. In a few seconds 
the tonic spasm relaxes, the movements become clonic or 
intermittent, the pupils dilated, the face cyanosed, and from 
the violent contraction of the masseters frothy saliva, often 
blood-streaked, pours from the mouth. The clonic spasms 
continue for a minute or two, and are generally followed by a 
period of coma lasting from a few minutes to several hours. 
Sometimes the patient returns at once to consciousness, and 
complains simply of weakness, muscular soreness, and mental 
confusion. More rarely the convulsion is followed by an out- 
25 



386 DISEASES OF THE NERVOUS SYSTEM. 

break of mania, or of epileptic automatism, a condition in 
which the patient performs some incongruous act. 

Petit Mai. — In this type the seizure consists of momentary 
unconsciousness, with pallor, and perhaps twitching of the 
muscle. The patient suddenly stops in the midst of his work 
or conversation, remains quiet for a few seconds, and then con- 
tinues where he left off, perhaps unconscious of the interrup- 
tion. Petit mat may be a forerunner of grand mal or may alter- 
nate with it. 

Between these two extremes, the seizures manifest all grades 
of severity. The frequency of the paroxysms varies consider- 
ably ; they may occur as seldom as once a year, or as often as 
ten or twelve times a day. A marked periodicity in their re- 
currence is often observed. 

The term " status epilepticus" is applied to a series of con- 
vulsions which follow each other in rapid succession, and 
which are associated with high fever. 

The epileptic may manifest no other symptoms beyond the 
convulsions, but when the latter are very frequent the health 
fails and the mental power deteriorates. 

Diagnosis. — The convulsions of idiopathic epilepsy must 
be distinguished from those due to organic brain disease (organic 
epilepsy). The latter affection rarely develops before twenty- 
five ; the aura may be connected with the special senses, which 
is uncommon in idiopathic epilepsy ; the convulsion is often 
confined to one member or to one side of the body, and may 
not be associated with unconsciousness (Jacksonian epilepsy) ; 
the convulsion may begin in one member and then become 
generalized ; and finally, in a large proportion of the cases of 
organic epilepsy, there will be a history or concomitant symp- 
toms of syphilis, or the evidence of cerebral injury. 

Urcemia. — Ursemic convulsions may be recognized by the 
history and the results of the urinary analysis. 

Prognosis. — Generally unfavorable. Arrest of the dis- 
ease is rare, but amelioration is often secured by treatment. 

Treatment. Preventive. — Careful search should be made 
for the cause which excites the paroxysms ; this will often be 
found in some disturbance of the gastro-intestinal tract. The 
diet should be light, and as a rule, largely vegetable. Con- 



APHASIA. 387 

stipatiou must be relieved by diet, exercise, or the use of mild 
laxatives. Undue mental and physical excitement should be 
avoided. Systematic exercise and frequent bathing followed 
by friction of the skin lessen the sensitiveness of the nervous 
system. The most reliable drugs are the bromides ; one or 
two drachms of a combination of the bromides of sodium, 
potassium, and ammonium may be given daily. The tendency 
to acne may be considerably lessened by the addition of a 
drop or two of Fowler's solution with each dose. A small 
amount of antipyrin often lessens the amount of the bromide 
required to check the convulsions. 

fy Amnion, bromid., gvj ; 
Antipyrin, 3J ; 
Liq. potass, arsenitis, f£j ; 

Aq. menthge pip., q. s. ad f^vj. — M. (Wood.) 
Sig. — Tablespoonful in water night and morning. 

When the bromides fail, one of the following remedies may 
be employed : oxide of zinc (gr. yj-xv a day), picrotoxin (gr. 
jjf-Q thrice daily), borax or belladonna. 

When an aura gives warning of a seizure, the inhalation of 
nitrite of amyl may abort it. 

Surgical interference is indicated in Jacksonian epilepsy, 
and in those cases in which the convulsion begins in one mem- 
ber and subsequently becomes generalized. 

The Attack. — Injury of the tongue may be prevented by 
placing a piece of cork between the teeth ; as the seizure is of 
short duration no special medication is required. In the status 
epilepticus, chloroform or nitrite of amyl may be administered 
by inhalation, and hyoscin (gr. t ^-q) or morphia given hypo- 
dermically. 

APHASIA. 

(Aphemia.) 

Definition. — An inability to express thoughts in words or 
to interpret perceptions. 

Motor or Ataxic Aphasia. — In this form the patient has 
lost the mechanism whereby thoughts are converted into words, 
although he may be able to repeat the words after another, to 



388 DISEASES OF THE NERVOUS SYSTEM. 

write them, or to read them. The lesion producing this form 
of aphasia is located in the left third frontal convolution. 

Agraphia is an inability to express thought in written lan- 
guage. It is usually associated with motor aphasia, 

Alexia is an inability to express written language in words. 
It is also commonly associated with motor aphasia. 

Sensory Aphasia. — This is an inability to interpret percep- 
tions. There are the following varieties : — 

Word-blindness. — This is au inability to interpret written 
language, The lesion is usually in the supramarginal and 
angular gyri of the left side. 

Word-deafness. — An inability to interpret spoken language. 
The lesion is in the posterior part of the first and second tem- 
poral convolutions. 

Mind-blindness (Apraxia, Visual Amnesia). — An inability to 
recognize the use or import of an object. Seeing an object 
awakens no intelligent idea of its use. 

Mind-deafness {Auditory Amnesia). — An inability to inter- 
pret sounds. The patient hears the words, can recognize 
and repeat them, but cannot interpret them. 

Paraphasia. — An inability to use the right word in continued 
speech. He can interpret and use words, but is constantly 
misplacing them. 

Amnesic Aphasia. — This term is employed to designate an 
entire loss of word- memory. It includes both motor and 
sensory aphasia. 

Pathology. — The lesions which produce aphasia are 
manifold ; the most important are : Tumor, gumma, abscess, 
depressed fracture, embolism, thrombus, or softening in the 
localities which correspond to the various forms of aphasia. 
In right-handed subjects the lesion is on the left side of the 
brain ; in the left-handed it may, however, be on the right side. 
Aphasia is not always due to organic disease ; it may be noted 
in congestion of the brain, in sudden fright, in the convales- 
cence of fevers, in migraine, after epileptic seizures, and in 
hysteria. 

Diagnosis. — Aphasia must be distinguished from aphonia. 
The latter condition is an inability to utter sounds, a power 
not lost in aphasia ; moreover, aphonia is generally dependent 



VERTIGO. 389 

upon some abnormality of the larynx or of the nerves leading 
thereto. 

Prognosis. — This depends entirely on the cause. After 
apoplexy the prognosis should be guarded. In cerebral soft- 
ening it is absolutely unfavorable. When aphasia develops 
in the young the outlook is much more hopeful. 

Treatment. — The causal condition will require attention. 
The patient may be instructed to speak and to interpret after 
the manner employed in teaching the young. 

VERTIGO. 

(Dizziness, Giddiness, Swimming in the Head.) 

Definition. — A sense of unstable equilibrium in which 
the patient himself or surrounding objects appear to be in a 
state of rapid oscillation or rotation. It is a symptom of 
many conditions. 

Etiology. — Vertigo may result from : — 

1. Cerebral anaemia or congestion. The dizziness preceding 
a fainting fit is an illustration of the former, and that follow- 
ing exposure to the rays of the sun is an illustration of the 
latter. Vertigo is often a pronounced symptom of chronic 
cerebral congestion and ansemia. The vertigo of chronic heart 
disease and of neurasthenia is included under this head. 

2. Reflex irritation. The most common example of this 
form is the vertigo dependent upon gastric disturbances. It 
is also noted in eye-strain, uterine disease, constipation, and 
disease of the internal ear. The last is termed labyrinthine 
vertigo, or Meniere's disease, and has been described elsewhere. 

3. Organic disease of the brain and cord. Cerebral tumor, 
meningitis, and softening are frequently associated with vertigo. 
It is often quite marked in cerebellar disease. It may be a 
pronounced symptom in disseminated sclerosis and locomotor 
ataxia. 

4. Toxic substances in the blood. The vertigo observed in 
lithsemia, uraemia, and diabetes is included under this head. 
When taken in large doses, certain drugs, as alcohol, bella- 
donna, cannabis indica, lobelia, and conium, may produce the 



390 DISEASES OF THE NERVOUS SYSTEM. 

symptoms It is often a marked symptom of chronic lead- 
poisoning. 

5. Epilepsy. Vertigo may precede, follow, or take the 
place of an epileptic seizure. 

6. Hysteria. Occasionally marked vertiginous attacks are 
connected with hysteria. 

7. Unknown causes. The term essential vertigo has been 
applied to those cases in which, after the most exhaustive 
study, no adequate cause can be ascertained. There is some- 
times an hereditary tendency to this form of vertigo. 

Diagnosis. — Vertigo must be distinguished from pepit mat, 
or minor epilepsy. The history, the presence of a definite cause, 
and the absence of unconsciousness and of convulsive move- 
ments will serve to separate vertigo from epilepsy. 

The determination of the cause of the vertigo must be 
based upon the history, the age at which it develops, and a 
critical examination of the various organs. 

Prognosis. — This will depend entirely on the cause ; when 
the latter can be removed, the prognosis is favorable. 

Treatment. — This must be directed to the causal condition. 

MENIERE'S DISEASE. 

(Labyrinthine Vertigo, Aural Vertigo.) 

Definition. — Paroxysmal vertigo, probably depending 
upon disease of the internal ear. 

Etiology and Pathology. — The exact cause of 
Meniere's disease is still undetermined. In some cases, how- 
ever, inflammatory changes have been observed in the semi- 
circular canals. It is probable that mild forms of the disease 
can be indirectly induced by lesions of the middle ear. 

Symptoms. — Frequently prodromes precede the attack, 
such as deafness Or earache. These, however, may be absent, 
and the attacks ushered in with extreme vertigo and tinnitus 
aurium. The latter is often compared to the escape of steam, 
the buzz of an insect, or the discharge of a cannon. The patient 
feels as if he or surrounding objects were being whirled vio- 
lently around, and in severe cases the face is pale and anxious ; 



HYSTEEIA. 391 

the surface is clammy ; there are Dausea and vomiting ; and the 
patient falls unconscious. 

As a rule, there is deafness in one ear at least, but ex- 
ceptionally, hearing may be quite normal. At first the 
paroxysms may occur at long intervals, but as the disease 
advances they become more frequent and the tinnitus and 
deafness become more marked. 

Diagnosis. — The paroxysmal vertigo, deafness, and tinnitus 
annum are the diagnostic features. 

Prognosis. — The prognosis should always be guarded. 
Some cases recover entirely, but in the majority the vertigi- 
nous attacks continue until the deafness in the affected ear 
becomes complete. 

Treatment. — The middle ear should be carefully ex- 
amined, and any existing disease treated. Severe counter- 
irritation by blisters, or the actual cautery applied behind the 
ear, may be of some service. Bromide of potassium or large 
doses of hydrobromic acid may give temporary relief. Charcot 
recommends quinine in sufficient doses to cause cinchonism. 

HYSTERIA. 

Definition. — Hysteria is a functional disease of the 
nervous system, manifested by symptoms of the most varied 
character, which apparently result from a loss of control over 
the production of nerve-power. 

Etiology. — Females are especially predisposed, although 
it occasionally develops in males. It is most common in early 
adult life and at the menopause. The nervous temperament 
and such ancestral diseases as epilepsy, insanity, etc., favor its 
development. 

Prolonged emotional excitement, such as worriment, anxiety, 
grief, and all causes which lower the vitality serve to excite 
it in susceptible individuals. 

Pathology. — No causal lesions can be detected after 
death. 

Symptoms. — The various manifestations may be described 
under three heads : (1) Motor, (2) sensory, and (3) psychical. 

Motor Phenomena. — Paralysis not infrequently results from 



392 DISEASES OF THE NERVOUS SYSTEM. 

hysteria ; it may take the form of a hemiplegia, paraplegia, or 
monoplegia, although the first is by far the most common. 
The paralysis is generally paroxysmal, and is frequently asso- 
ciated with contractures and anaesthesia. The affected muscles 
do not waste. 

Local paralysis is also common ; thus there may be aphonia 
from paralysis of the vocal cords ; dysphagia, from paralysis 
of the oesophagus ; and incontinence of urine, from paralysis 
of the bladder. 

Convulsive seizures are common manifestations of hysteria, 
and may closely simulate the paroxysms of true epilepsy ; but 
there is no aura; the patient usually falls in a comfortable 
place ; consciousness is only apparently lost, for after the seiz- 
ure she remembers all that has transpired ; the tongue is rarely 
bitten ; the eyes are partially closed ; the face is expressive of 
some emotion ; screaming or sobbing is of frequent occurrence ; 
the movements are apt to be tonic, so that the patient assumes 
the position of opisthotonos, or if clonic, they are apt to be 
violent and purposive ; the seizures are of long duration, and 
may be continued for several hours or days, and firm pressure 
over the ovaries may exaggerate or re-excite them. 

The spasms may be local ; thus there may be retention of 
urine, from spasm of the bladder ; asthma, from spasm of the 
bronchi ; hiccough, from spasm of the diaphragm ; persistent 
vomiting, from spasm of the stomach ; dysphagia, from spasm 
of the oesophagus ; and a " phantom tumor," from spasm of 
abdominal muscles associated with flatulent distention of the 
intestines. 

Among other motor phenomena may be mentioned obsti- 
nate tremors, choreiform movements, and contractures of cer- 
tain groups of muscles. 

Sensory Phenomena. — There may be a complete loss of sen- 
sation in certain parts, as one side of the body. Anaesthesia 
without other nervous phenomena is usually hysterical. In 
some cases tactile sensation is preserved and there is a loss 
only of thermic or painful sensations. The anaesthetic part is 
often unusually pale, and when pricked with a needle fails to 
bleed (ischaemia). 

The special senses may be involved ; thus there may be con- 



HYSTEKIA. 393 

traction of the field of vision, complete blindness, loss of smell, 
loss of taste, or loss of hearing. These special-sense palsies 
are usually transient, and often alternate with one another. 

Instead of anaesthesia, there may be hyperesthesia or pain. 
Severe pain in the stomach may simulate gastralgia. An ex- 
quisitely painful and tender condition of the abdomen may 
be mistaken for peritonitis. A localized pain in the head, 
described as resembling the effect of a nail being driven into it, 
is termed hysterical clavus. The joints sometimes become 
swollen and very tender, resembling arthritis (neuromimesis). 

Intense pain over the heart may simulate angina pectoris. 
The spine is often the seat of hyperesthesia, especially in spots, 
and this spinal irritation is often associated with pain in parts 
corresponding to the distribution of nerves which have their 
origin in the hypersesthetic area. 

A very common abnormal sensation is the globus hystericus, 
i. e., a feeling as of a ball rising in the throat and impeding 
respiration. 

Psychical Phenomena. — Frequently the only conspicuous 
mental phenomenon is the great lack of will-power ; but gen- 
erally the patients are more or less excitable, highly mercurial, 
and easily moved to laughter or tears. They frequently mani- 
fest a great fondness for sympathy, and this, in connection with 
their weak will-power and lowered moral tone, often leads them 
to feign symptoms which they really do not have. Among 
the more serious mental manifestations may be mentioned 
insanity, ecstasy, catalepsy, and trance. 

Diagnosis. — The recognition of hysteria is often attended 
with great difficulty, especially as it is frequently associated with 
symptoms which really have an organic basis. In making a 
diagnosis, the history, sex, and temperament must be carefully 
considered. The manifestations usually develop abruptly ; 
are generally paroxysmal ; appear without obvious cause ; 
often subside spontaneously under some emotional excitement ; 
rarely lead to any impairment of the health ; and are usually 
associated with a history of other hysterical phenomena. 

Prognosis. — As regards life the prognosis is good. In 
rare instances death has followed exhaustion induced by re- 
peated convulsions or prolonged fasting. While hysteria 



394 DISEASES OF THE NERVOUS SYSTEM. 

usually ends in recovery, the duration of the illness is a mat- 
ter of great uncertainty. 

A speedy recovery is to be expected in those cases where 
the hysterical phenomena are connected with some obvious 
cause which can be removed. 

Treatment. — Careful search should be made for some 
exciting cause, which, if found, should be removed as far as 
possible. The physical condition is generally reduced, and 
careful study must be given to the diet, exercise, amusement, 
clothing, etc., with the view of improving it. Tonics like 
iron, arsenic, strychnia, hypophosphites, cod-liver oil, and 
malt are often indicated, and they may be advantageously 
combined with nerve sedatives like valerian, asafcetida, sumbul, 
and the like ; in the milder manifestations, the following pill 
may prove useful : — 

I$l Acid, arseniosi, gr. ^ ; 

Ferri sulph. ex., 

Ext. sumbul., aa gr. xx ; 

Assafoetidee, gr. xl.— M. (Goodell.) 
Ft. in pil. No. xx. 
Sig.— One after each meal. 

Or— 

I£ Quinin. valerianat., 

Zinci valerianat., 

Ferri valerianat., aa gr. xxiv. — M. 
Ft. in pil. No. xxiv. 
Sig. — One, thrice daily. 

The more thoroughly the physician is able to inspire con- 
fidence and to control his patient, the more likely is he to 
effect a cure. Firmness tempered with kindliness and en- 
couragement is essential to success. 

While hypnotism appears to have been somewhat useful in 
France, in this country, although employed but to a limited 
extent, it has not given encouraging results, and moreover, in 
the event of failure, seems capable of aggravating the hysteri- 
cal condition. 

In long-continued convulsive seizures, cold water may be 
dashed on the face and chest, or hyoscine administered 
hypodermically. In obstinate cases an anaesthetic should be 
employed. In the various form of paralysis electricity is 



NEURASTHENIA. 395 

often useful. In some eases static electricity, no doubt from 
the profound mental effect which it has induced, has given 
excellent results. 

In aggravated cases the " rest-cure" introduced by S. Weir 
Mitchell is often applicable. It consists in isolation from 
sympathizing friends aud relatives ; abundant feeding, espe- 
cially with milk; and complete rest of body and mind with 
passive exercise obtained by massage and electricity. 

NEURASTHENIA. 

(Nervous Prostration.) 

Definition. — A term applied to a group of symptoms 
apparently resulting from exhaustion of the nerve-centres. 

Etiology. — A neuropathic tendency, prolonged mental 
work, or emotional excitement, excesses, and irregular living 
are general predisposing factors. 

Symptoms. Cerebral Symptoms. — Depression of spirits, 
indisposition, inability to concentrate the mind on one subject 
for any length of time, insomnia, vertigo, headache, irritability 
of temper, and hysterical manifestations. 

Spinal Symptoms. — Sometimes these predominate, when the 
condition is termed spinal irritation, and its chief manifesta- 
tions are : Pain in the back, spots of tenderness along the 
spine, weakness of the extremities, great prostration after 
moderate exertion, aud various subjective phenomena, such as 
numbness, tingling, formication, and neuralgic pains. 

Gastro-intestinal Symptoms. — Anorexia, coated tongue, and 
constipation. 

Circulatory Symptoms. — Palpitation, cold extremities, and 
sometimes violent pulsation of the aorta. 

Sexual Symptoms. — In females, amenorrhoea or dysmenor- 
rhea ; in males, impotence or spermatorrhoea. 

The disease is inseparably associated with cerebro-spinal 
ansemia, hysteria, and hypochondriasis. 

Diagnosis. — The diagnosis is rarely difficult. Before 
relegating a case to this class, care must be taken to exclude 
organic disease, and such general disorders as lithaimia. 



396 DISEASES OF THE NERVOUS SYSTEM. 

Prognosis. — When the cause can be removed and the 
patient controlled, the prognosis is favorable. 

Treatment. — The treatment is largely hygienic and die- 
tetic, and will vary considerably in different cases. Where 
there has been inactivity, regulated physical exercise will be 
of great value ; on the other hand, the weak and anaemic will 
require rest. In the latter case, the plan of treatment intro- 
duced by S. Weir Mitchell, and known as the "rest-cure," 
often gives brilliant results. In all cases careful attention 
must be given to the diet, bathing, and clothing, and the 
patient assured that he is suffering from no incurable disease. 
Frequent bathing with salt water, followed by friction of the 
skin, will often add to the general vigor. Tobacco and alco- 
hol must be interdicted, and tea and coffee used very sparingly. 
Tonics like iron, arsenic, quinine, strychnia, and phosphorus 
are often indicated. 

CHOREA. 

(Chorea Minor, St. Vitus' s Dance.) 

Definition. — A nervous affection occurring especially in 
children, and characterized by irregular movements which in- 
crease under excitement and cease during sleep. 

Etiology. — Childhood (between five and fifteen), female 
sex, nervous temperament, and the rheumatic diathesis are 
general predisposing factors. It sometimes develops suddenly 
after mental or emotional excitement, such as anxiety, fear, or 
grief. It may be excited by reflex irritation, as an adherent 
prepuce, intestinal parasites, etc. It not infrequently develops 
in the course of pregnancy. 

Pathology. — It is customary to look upon chorea as a 
neurosis, since no constant lesions have been discovered to 
account for its clinical manifestations. In some cases endo- 
carditis, and emboli in the minute cerebral vessels have been 
discovered, but their relation to chorea has not yet been de- 
termined. 

Symptoms. — The first manifestations are usually restlessness 
and awkwardness in movement. The child cannot remain 
still, but is constantly raising its shoulders, jerking its head, 



CHOREA. 397 

twisting its fingers, or shuffling its feet. Frequently these 
symptoms develop so insidiously that the disease is not recog- 
nized, and the child is punished for being fidgety. 

When the disease is fully established the disorderly move- 
ments become more marked, and may be confined to one 
member or may involve the entire body. When the facial 
muscles are affected, the most grotesque expressions are pro- 
duced ; involvement of the arms may interfere with eating 
and dressing ; when the legs suffer the gait becomes jerking 
and stumbling ; involvement of the larynx causes stammering ; 
and spasm of the muscles of deglutition induces difficult 
swallowing and choking-spells. When the attention is directed 
to the movements they invariably grow worse, but they 
diminish during repose and cease entirely during sleep. 
Sometimes, in addition to the involuntary movements, there is 
a distinct loss of power in the affected members. The general 
health is usually more or less impaired. The child is anaemic; 
the temper is irritable ; and the mental power deficient. Aus- 
cultation of the heart often detects a murmur which may be 
either an expression of anaemia or of complicating endocarditis. 

In some cases (chorea insaniens) the movements are so 
violent that the patient is unable to walk, eat, or even to lie 
down. Fever develops, and ultimately the mind becomes de- 
lirious. Death frequently results from exhaustion. This form 
is usually observed in adults, and especially in primiparae. 

Diagnosis. — The recognition of chorea is rarely attended 
with -difficulty. Disseminated spinal sclerosis may be dis- 
tinguished by the presence of nystagmus, a scanning speech, 
increased reflexes, and a rhythmical tremor which is only ex- 
cited by movement. 

Prognosis. — In simple chorea recovery usually follows in 
the course of two or three months. Death from heart com- 
plications is a rare termination. Relapses are not infrequent. 
Among the possible sequelae may be mentioned imbecility and 
chronic chorea. 

Chorea insaniens frequently terminates fatally through ex- 
haustion. 

Treatment. — Rest of body and mind is an essential ele- 
ment of the treatment. The child should be taken from 



398 DISEASES OF THE NERVOUS SYSTEM. 

school and placed under the most favorable hygienic condi- 
tions. Careful search should be made for reflex irritation, 
such as adherent prepuce, intestinal parasites, eye-strain, etc. 
All excitemeut must be avoided. Amusement in the open air 
when the weather is fine is to be recommended. As the child 
is generally anaemic, iron is indicated in the majority of cases. 
Among the special remedies arsenic holds the first place. Fow- 
ler's solution may be given in doses of two drops thrice daily, 
gradually increased to eight or ten drops thrice daily. Among 
other remedies may be mentioned the fluid ext. of cimicifuga 
(Xx increased to 3j thrice daily), hyoscyamine (gr. T | 1 qo )> 
and anti pyrin (gr. vj t. d.). 

In Chorea msaniens forced feeding should be resorted to. 
Morphia and other sedatives may be employed hypodermi- 
cally. Chloroform may be required to control temporarily 
the movements. Severe cases of chorea complicating preg- 
nancy will call for the induction of premature labor. 

PARALYSIS AGITA1VS. 

(Parkinson's Disease, Shaking Palsy.) 

Definition. — A chronic nervous disease, characterized by a 
fine, slowly-spreading tremor, muscular weakness and rigidity, 
and a peculiar gait, termed festi nation. 

Etiology. — Advanced life, a neuropathic tendency, mental 
strain, and exposure to cold and wet are predisposing factors. 
It sometimes develops suddenly after intense mental or emo- 
tional excitement. 

Pathology. — The pathology is unknown. No definite 
lesions have been found to account for the clinical manifesta- 
tions. 

Symptoms. — In some cases the onset is abrupt, but more 
commonly the disease develops insidiously. The first symptom 
is usually a fine tremor beginning in the hand or foot, which 
may slowly spread until it involves all the members; the 
head is rarely affected. At first the tremor may be parox- 
ysmal, but as the disease advances it becomes almost continuous. 
Excitement increases it, but it is noteworthy that physical 
effort temporarily diminishes or checks it The face becomes 






PARALYSIS AGITANS. 399 

expressionless, and the speecn slow and measured. Later, 
muscular rigidity develops ; the head is bowed, the body bent 
forward, the arms flexed, the thumbs turned into the palms 
and grasped by the fingers, and the knees slightly bent. At 
this time the gait is characteristic : the steps grow faster and 
faster, the body inclines more and more forward until the 
patient falls, seeks support in some neighboring object, or 
straightens himself by a supreme effort of the will. The term 
fedhiation has been applied to this peculiar gait. Occasionally 
a tendency to fall backwards — retropulsion — replaces festina- 
tion. The rigidity and muscular weakness render all move- 
ments slow and labored. 

. Intelligence is usually good. There is no anaesthesia, but 
there are various manifestations of paresthesia, such as numb- 
ness and tingling ; a sensation of heat is especially noted. In 
some cases free perspiration has been observed. 

Diagnosis. — The tremor, rigidity, weakness, flexion of the 
body and members, lack of facial expression, and festination 
are the diagnostic features. In some cases the tremor is absent. 
Paralysis agitans must be distinguished from disseminated 
sclerosis. In the latter the tremor is coarse, is frequently ab- 
sent when the patient is quiet, and is made worse by efforts to 
control it ; cerebral symptoms are generally present ; nystag- 
mus is often noted ; and the attitude and gait are entirely 
different from those of paralysis agitans. 

Prognosis. — -Recovery rarely, if ever, occurs. In some 
cases, after reaching a certain point, the disease remains sta- 
tionary. The progress is slow and the duration indefinite. 

Treatment. — Measures intended to improve the tone of 
the system are indicated ; these are : A regulated diet, rest of 
body and mind, frequent bathing followed by friction of the 
skin, and the use of such tonics as iron, arsenic, and phos- 
phorus. The rigidity and tremors are sometimes improved by 
massage and electricity. Among the remedies recommended 
for the tremors are bromide of potassium, hyoscyamine 
(gr. t^-o), and hyoseine (gr. T ^j), but the improvement follow- 
ing their use is only slight and temporary. 



400 DISEASES OF THE NERVOUS SYSTEM. 

ARTISANS' CRAMP. 

Definition. — A spasmodic affection of the muscles in- 
duced by prolonged work requiring delicate coordination, and 
occurring only in the performance of that particular work. 

Etiology. — It is more common in men than in women, 
and the nervous temperament predisposes to its development. 
The occupations in which it is most apt to occur are writing, 
piano-playing, sewing, and telegraphing. 

Pathology. — The disease is evidently not peripheral, for 
when the other hand is substituted the condition soon develops 
in that member. It is probably dependent upon unnatural 
irritability of the nerve-centres. 

Writers' Cranip. 

(Graphospasm, Scriveners' Palsy.) 

Symptoms. — The condition usually begins with a sense of 
fatigue, weight, or actual pain in the affected muscles. Soon 
the fingers are seized with a tonic or clonic spasm whenever 
the pen is grasped (spastic form). In some cases the hand 
when put into use becomes the seat of a decided tremor 
(tremulous form) ; in a third group of cases the chief phe- 
nomena are excessive weakness and fatigue, which disappear 
as soon as the pen is laid aside (paralytic form). 

Prognosis. — Guardedly favorable. The disease is obsti- 
nate, but cure generally follows protracted rest. 

Treatment. — Absolute rest is the essential element of 
treatment. The general condition should be improved by 
iron, arsenic, strychnia, and cod-liver oil. Massage, electricity, 
and passive movements give good results. 

TETA]ST. 

(Tetanilla, Intermittent Tetanus.) 

Definition. — A nervous affection, characterized by tonic 
spasms which are usually paroxysmal and involve the ex- 
tremities. 

Etiology. — It is most frequently observed in the young. 
In women it is frequently associated with pregnancy or lacta- 



401 

tion. It is sometimes excited by exposure, emotional excite- 
ment, or one of the infectious fevers. An epidemic form has 
been described, but some of the outbreaks seem to have been 
hysterical. A very grave form has been induced by thyroid- 
ectomy and by lavage in gastric dilatation. 

Symptoms. — The patient is seized with bilateral tonic 
spasms in the arms and legs. The jaws are rarely involved. 
The contractions are usually paroxysmal and are attended with 
pain. As was pointed out by Trousseau, they can be induced 
by pressure over the arteries and nerves of the affected limb. 
The electro-contractility of the muscles is greatly exaggerated. 
There may be slight oedema. Sensation is not disturbed ; the 
mind is clear ; and fever is slight or entirely absent. 

Diagnosis. — Hysteria may simulate tetany, but the history 
and the unilateral character of the contractions will distinguish 
it from tetany. 

Tetanus. — In this disease the spasms are continuous and 
early involve the jaws and trunk. 

Prognosis. — Usually favorable. Attacks following thy- 
roidectomy and lavage sometimes prove fatal. 

Treatment. — Good hygiene ; tonics ; electricity ; sedatives 
like bromide of potassium, belladonna, and chloral. Warm 
or cold baths, followed by friction. 

THOMSEN'S DISEASE. 

(Congenital Myotonia.) 

Definition. — A disease confined to certain families, and 
characterized by tonic spasms of the muscles, induced by 
voluntary movements. 

Etiology. — The disease is usually congenital, and trans- 
mitted from one generation to another. Several members of 
the same family are commonly affected. 

Pathology. — Unknown. 

Symptoms.— The disease appears in early childhood, and is 
manifested by a tonic spasm of the muscles every time they 
are put in use ; this is especially marked after periods of in- 
activity. In a few moments the rigidity wears away and the 
movements become free. From repeated contractions the 
26 



402 DISEASES OF THE NERVOUS SYSTEM. 

muscles become firm and extremely well developed. Under 
electrical stimulation the muscles contract and relax slowly. 

Prognosis. — Incurable. 

Treatment. — The condition improves under physical 
exercise. 

EXOPHTHALMIC GOITRE. 

(Graves's Disease, Basedow's Disease.) 

Definition. — A nervous affection, characterized by pro- 
trusion of the eyeballs, enlargement of the thyroid gland, and 
palpitation. 

Etiology. — Early adult life, female sex, and nervous tem- 
perament are the predisposing causes. It sometimes develops 
suddenly under emotional excitement, such as fright, grief, 
and anxiety. 

Pathology. — In most cases no lesions are found after 
death to account for the symptoms. It has generally been 
regarded as a disease of the sympathetic system, and in some 
instances changes have been found in the cervical ganglia; 
but the mental phenomena and the accelerated pulse cannot 
be explained on the theory of sympathetic paralysis. The 
prominence of the eyeballs is for the most part due to dilata- 
tion of the vessels in the back of the orbits ; and the enlarge- 
ment of the thyroid gland is due to a similar condition. 

Symptoms. Cardiac Phenomena. — Acceleration of the 
pulse (100° -150°) and palpitation, both greatly exaggerated 
by excitement ; hypertrophy of the heart from its rapid 
action ; occasionally a soft systolic murmur at the apex. 

Ocular Phenomena. — Bilateral protrusion of the eyeballs, 
and the " Grafe sign," which consists in a failure of the upper 
lid to follow the eyeball when the latter is directed downwards. 
Vision is usually unimpaired. 

Thyroid Phenomena. — Enlargement of the thyroid is often 
the last symptom to appear ; one or both lobes of the gland 
may be affected. Inspection reveals enlargement with pulsa- 
tion ; palpation detects a soft swelling and a purring thrill ; 
auscultation may yield a bruit. 



Raynaud's disease. 403 

Nervous Phenomena. — The following are sometimes ob- 
served : A tremor of the hands or of the entire body ; hypo- 
chondriasis ; acute mania ; or vitiligo and chloasma. 

General Phenomena. — Anaemia, failure of health and 
strength, and slight febrile paroxysms. 

Diagnosis. — It should be borne in mind that one of the 
three important symptoms may be absent throughout the 
disease. In some cases palpitation and throbbing of the 
cervical vessels may be the only phenomena. 

Goitre may be distinguished from exophthalmic goitre by the 
absence of cardiac, ocular, and nervous symptoms. 

Prognosis. — The disease generally runs a protracted course. 
Some cases recover entirely ; many improve and subsequently 
relapse ; a few die, after a short illnes,s from heart failure or 
acute mania. 

Treatment. — The general nutrition must be improved by 
rest, a liberal diet, and the use of such tonics as iron, quinine, 
and arsenic. The application of mild galvanic currents to the 
neck is often very useful. When the palpitation is marked, 
prompt relief often follows absolute rest and the application 
of an ice-bag to the prascordia. The most reliable internal 
remedies are strophanthus, digitalis, belladonna, and ergot. 
Bromide of potassium is sometimes useful in controlling the 
nervous symptoms. 

Operative Interference. — Ligation of the arteries and ex- 
tirpation of the gland cannot be recommended. 

RAYNAUD'S DISEASE. 

(Symmetrical Gangrene.) 

Definition. — A vaso-motor neurosis, characterized by local 
anaemia, congestion, or gangrene. 

Etiology. — The cause is unknown. The disease probably 
consists in a local spasm or paresis of the vessels. 

Symptoms. — In one form the part, usually the finger, be- 
comes extremely pale, cold, and anaesthetic (local syncope). 
After a variable time these phenomena disappear and are fol- 
lowed by redness, heat, and tingling; such attacks maybe 
excited by cold, and come and go without damaging the part. 



404 DISEASES OF THE NERVOUS SYSTEM. 

In another form the affected part becomes swollen, dark red, 
and painful {local asphyxia), and if the attack persists bullae 
may appear and gangrene develop. The gangrenous areas 
are often symmetrical, involving a finger on each hand, a toe 
on each foot, or both ears. Hemoglobinuria is not uncommon 
during the attack. 

Prognosis. — The attacks persist, but life is not endangered. 
In rare instances extensive gangrene develops and is followed 
by death. 

Treatment. — Patients liable to attacks should be well 
protected against cold. Tonics are often indicated. Frequent 
bathing followed by friction is useful. Raynaud advises the 
use of a continued current, one pole over the spine and the 
other over the affected area. 

ACUTE ANGIO-NEUROTIC (EDEMA. 

Definition. — A neurosis characterized by transient circum- 
scribed oedema developing without obvious cause. 

Etiology. — Beyond a distinct hereditary tendency nothing 
is known of its cause. According to Quincke, there is a tem- 
porary vaso-motor dilatation of the vessels followed by the 
transudation of serum. 

Symptoms. — (Edematous swelling suddenly appears in some 
part of the body, particularly in the face and hands. Coinci- 
dent with the oedema there may be marked gastro-intestinal 
symptoms such as vomiting, gastralgia, and colic. The disease 
is allied to urticaria and the latter may precede the outbreak. 

The attacks may occur at intervals of a few weeks. 

Prognosis. — The peculiar tendency persists ; unless the 
larynx is involved, it is unattended with danger. 

Treatment. — General tonics, like iron, quinine, and strych- 
nia, are sometimes useful. 

MYXCEDEMA. 

Definition. — A nervous affection, characterized by mucoid 
degeneration of the subcutaneous tissues, atrophy of the thy- 
roid gland, and mental impairment. 



FACIAL HEMI- ATROPHY — ACROMEGALIA. 405 

Etiology. — The causes are unknown. It is of more 
frequent occurrence in women than in men. 

Symptoms. — It is manifested by swelling, particularly 
marked in the face and upper extremities. Unlike simple 
oedema, the parts do not pit on pressure. The skin is harsh 
and dry. The thyroid gland is atrophied. Among other 
symptoms are failure of memory, slowness of thought and 
speech, unsteady gait, and, towards the close, dementia. 

Congenital myxoedema is observed in cretinism, and a 
similar condition sometimes follows removal of the thyroid. 

Prognosis. — The disease runs a protracted course, and is 
incurable. 

Treatment. — Palliative. 

FACIAL HEMI- ATROPHY. 

(Unilateral Progressive Atrophy of the Face.) 

Definition. — A rare affection. Characterized by progres- 
sive wasting of tissues — bones and soft parts — on one side of 
the face. 

Etiology. — The disease usually develops in childhood. It 
has been excited by injury of the face. 

Pathology. — In the few cases examined chronic trigeminal 
neuritis or lesions of the Gasserian ganglion have been dis- 
covered. 

Symptoms. — The first phenomenon is often discoloration of 
the skin ; this is soon followed by a slow wasting of all the 
tissues on the affected side of the face. The hair falls ; the 
eye is sunken ; and the teeth drop out. 

Prognosis. — The disease is progressive and incurable. 

ACROMEGALIA 

(Marie's Disease.) 

Definition. — A nutritional disease, characterized by en- 
largement of the bones and overlying tissues, chiefly of the 
hands, feet, and face. 

Etiology. — Unknown. It usually develops in earlv adult 
life. 



406 DISEASES OF THE NERVOUS SYSTEM. 

Pathology. — Examination of the bones reveals a true 
hypertrophy, particularly of the cancellous structures. In 
some cases the pituitary body has been very much hypertro- 
phied and the thymus gland persistent. 

Symptoms. — The hands and feet are considerably enlarged, 
especially in breadth ; the fingers and toes are stumpy and the 
nails are flat and small. Hypertrophy of the inferior maxil- 
lary bone leads to elongation of the face and protrusion of the 
lower jaw. The lips are large and everted. Among occa- 
sional symptoms may be mentioned spinal curvature, polyuria, 
glycosuria, persistent headache, deafness, blindness from 
atrophy of the optic nerve, loss of sexual power, and in women, 
menstrual disorders. 

Diagnosis. — Acromegalia might be mistaken for myxe- 
dema, but in the latter the soft parts only are involved ; the 
skin is firm and adherent, instead of soft and mobile as in 
acromegalia ; and the face is round. 

In Paget' s osteitis deformans the long bones are especially 
involved, and are not only enlarged, but considerably deformed ; 
and the face has a peculiar triangular shape. 

Prognosis. — The affection is incurable, but the duration is 
indefinite. 

Treatment. — So far, remedies have been futile. 

SUNSTROKE. 

(Heat-stroke, Thermic Fever, Coup de Soleil, insolation, Heat- 
exhaustion.) 

Definition. — An affection resulting from exposure to ex- 
cessive heat. 

Varieties. — Two varieties are observed : Thermic fever 
and heat-exhaustion. 

Thermic Fever. 

Pathology. — After death from thermic fever rigor mortis 
develops early and is marked. The various organs, especially 
the brain, are deeply congested. The left ventricle is firmly 
contracted, and the right is dilated and filled with blood. The 






SUNSTROKE. 407 

blood is dark and uncoagulated. Microscopic examination 
of the tissues reveals parenchymatous degeneration, or cloudy 
swelling. 

Symptoms. — Prodromes are frequently present and consist 
of exhaustion, vertigo, nausea, and headache. These symp- 
toms are followed by coma, and in this state the face is flushed ; 
the eyes are injected ; the skin is dry and burning • the tem- 
perature ranges from 106° to 112° ; the pupils are contracted ; 
the respirations are rapid and noisy ; and the pulse is full and 
rapid. Unless the temperature soon falls the respirations 
become shallow, the pulse weakens, and death results in a 
few hours. There is a very malignant form in which the 
patient is suddenly stricken comatose and dies in a few hours 
from cardiac failure. 

Sequelae. — Meningitis ; epilepsy ; insanity ; failure of 
memory ; and extreme sensitiveness to high temperature. 

Diagnosis. — The conditions under which the coma has de- 
veloped, together with the extremely high temperature of the 
body, will serve to distinguish sunstroke from apoplexy, alco- 
holism, and uraemia. 

Prognosis. — Very guarded. Probably forty per cent, 
perish. 

Treatment. — The patient should be promptly placed in a 
bath of ice water and should be rubbed with ice. Ice-water 
enemata are also useful. Antipyrin has been administered 
subcutaneonsly with good results. When the pulse is full 
and strong venesection may be a valuable adjunct to the anti- 
pyretic treatment. 

Heat-exhaustion. 

Pathology. — According to Wood, heat-exhaustion depends 
on a vaso-motor paresis, as a result of which there is a deter- 
mination of blood from the brain and surface of the body to 
the great bloodvessels of the abdomen. 

Symptoms. — The mind is dazed, but consciousness is not 
lost ; the surface is pale and cold ; the skin is moist ; the res- 
pirations are shallow and hurried ; and the pulse is rapid and 
feeble. 



408 DISEASES OF THE NERVOUS SYSTEM. 

Prognosis. — Recovery soon follows under appropriate treat- 
ment. 

Treatment. — The patient should be covered with hot 
blankets, and hot bottles should be placed near the feet. 
Brandy, ammonia, and strong coffee are useful stimulants. 
Strychnia hypodermically is a very efficient remedy. 

ALCOHOLISM. 

(Dipsomania.) 

Acute Alcoholism. — After excessive indulgence in alcohol 
the following symptoms are observed : Flushing of the face, 
quickening of the pulse, and mental exhilaration, followed by 
incoherent speech, loss of coordination, vomiting, delirium, 
slow pulse, subnormal temperature, and, finally, stupor and 
coma. Occasionally the coma is replaced or interrupted by 
convulsive seizures. In the majority of cases, recovery follows 
in the course of a day or two ; but sometimes the coma deepens 
and death results. 

Chronic Alcoholism. — This condition is characterized by a 
fine tremor, mental impairment, disturbed sleep, injection of 
the conjunctivae, redness of the nose (acne rosacea), and the 
symptoms of chronic gastro-intestinal catarrh, namely, ano- 
rexia, coated tongue, fetid breath, nausea, vomiting, fulness 
and distress after eating, and constipation alternating with 
diarrhoea. When the habit is long continued, atheroma of the 
arteries, cirrhosis of the liver, and chronic interstitial nephritis 
are apt to develop. 

A very common complication of chronic alcoholism is 
delirium tremens (mania a potu). This condition usually 
follows a protracted debauch, or spree, or is excited by an in- 
jury or some intercurrent disease. Its chief manifestations are : 
Mental excitement, insomnia, incoherent speech, disordered 
intellect, tremors, and hallucinations, usually of sight and hear- 
ing. The last are of a terrifying character ; the patient hears 
threatening voices, or sees repulsive creatures — snakes, rats, 
loathsome insects, or demons — peering at him from behind 
every piece of furniture. In some cases the terror excited by 
these hallucinations is so great that, in a fit of maniacal ex- 






ALCOHOLISM. 409 

citement, the patient rushes out into the street or jumps from 
the window. The pulse is rapid and feeble ; the appetite is 
entirely lost ; the bowels are constipated ; and the temperature 
usually elevated (101° -103°). 

In favorable cases, in the course of a few days or a week, 
the excitement abates, the appetite returns, sleep is restored, 
and convalescence established. In unfavorable cases, typhoid 
symptoms are apt to develop ; these are : Irregular fever, 
weak pulse, dry, brown tongue, stupor, subsultus tendinum, 
carphologia, and finally, complete coma. 

Among other complications or sequelae of dipsomania may 
be mentioned : Multiple neuritis, pneumonia, epilepsy, chronic 
meningitis, paretic dementia, and various psychoses. 

Diagnosis. — The coma of alcoholism must be distinguished 
from the coma of other diseases. The history, the absence of 
paralysis, the subnormal temperature, the fact that the patient 
can be aroused by screaming in the ear, or by firm pressure 
over some sensitive spot like the supraorbital notch, the odor 
on the breath, and the absence of other cause" will usually 
prevent an error in diagnosis. 

Delirium tremens is recognized by the history, restlessness, 
delirium, tremors, and terrifying hallucinations. 

The tremors of chronic alcoholism may be recognized by the 
history, the associated evidence of alcoholism, and by the fact 
that they are worse in the morning, and improve after the use 
of the stimulant. 

Prognosis. — In acute alcoholism the prognosis should be 
guardedly favorable. In delirium tremens recovery generally 
follows, unless there is great debility. In alcoholic pneumonia 
the outlook is grave ; recovery is exceptional. In alcoholic 
neuritis the symptoms usually subside under appropriate 
remedies and abstinence from the stimulant. 

In chronic alcoholism the prognosis is generally unfavorable. 
When the habit is fully established, it is rarely permanently 
broken ; temporary improvement is only too often followed by 
a relapse. 

Treatment. Acute Alcoholism. — The stomach should be 
emptied by the stomach-pump, a stimulating emetic, or the 
hypodermic injection of apomorphia (gr. xV~i)* If the coma 



410 DISEASES OF THE NERVOUS SYSTEM. 

persists and the pulse weakens, cardiac stimulants like 
ammonia, strychnia, and digitalis should be administered 
hypoderniically. Douching and flagellation may also be 
employed to arouse the patient. 

Delirium Tremens. — Alcohol must be withheld unless the 
pulse is very weak. It is essential that the patient should 
receive sufficient nourishment, for usually little food has been 
taken during the debauch which led to the delirium. Highly- 
seasoned beef-tea and milk with lime-water are the best foods. 
Sleep must be secured by chloral (gr. xx), bromide of potassium 
(3ss-3j), hyoscine (gr. y^-q), morphia (gr. J, and repeated once 
or twice), or paraldehyde (5j). When the pulse is weak, 
strychnia (gr. -£$, repeated, watching the effect) is often of 
great value. In most cases physical restraint is essential ; it 
is best secured by strapping the patient to the bed with sheets. 

Chronic Aleoholism. — It is necessary that -alcohol shall be 
withdrawn ; the rapidity with which this can be accomplished 
will depend on the circumstances. In most cases the tempta- 
tion to drink is so strong that confinement in an inebriate 
asylum is essential, to the success of the treatment. Various 
substitutes have been recommended for alcohol, among which 
may be mentioned bromide of potassium, chloral, cocaine, 
hyoscine, and cannabis indica. As a rule, they accomplish 
little beyond quieting the patient aud occasionally securing 
sleep. The diet should be nutritious, and carefully adapted 
to the condition of the stomach, which is usually the seat of 
chronic catarrh. Tonics like iron, quinine, and strychnia are 
often indicated. Graduated physical exercise is sometimes of 
decided value. 



OPIUM-POISONING. 

Acute Poisoning. Symptoms.- — A stage of excitement is 
followed by stupor, coma, contracted pupils, slow respirations, 
muscular relaxation, and a slow pulse. In the final stage the 
respirations become shallow and irregular, the pulse rapid and 
feeble, and the pupils dilated. 

Treatment. — The stomach should be emptied by a stimu- 
lating emetic or the stomach-pump. Strong coffee may be 






CHROMIC LEAD-POISONING. 411 

given by the mouth. The patient should be aroused by 
flagellation, douching, forced walking, or the electric brush. 
The physiological antidotes — atropia and strychnia — should 
be given hypodermically in full doses, their effects being care- 
fully watched. Electricity may be employed to stimulate 
respiration. 

Morphine-habit. {Morphinism, Morphiomania.) Symp- 
toms. — Anaemia, sallow complexion, an irresistible craving 
for the drug, dilated pupils, tremors, loss of appetite, restless- 
ness, insomnia, mental impairment, and a complete perversion 
of the moral nature. 

Treatment. — Confinement in an asylum is nearly always 
necessary. The opium should be withdrawn gradually. Such 
substitutes as cocaine, chloral, hyoscine, paraldehyde, and 
sulphonal may be employed temporarily. Respiratory stimu- 
lants like strychnia, and cardiac stimulants like digitalis, are 
often indicated. In the vast majority of cases the habit is 
only suspended, not broken. 

CHRONIC LEAD POISONING. 

(Plumbism, Saturnism.) 

Etiology. — Chronic lead-poisoning results from the slow 
absorption of lead, and is most commonly observed in work- 
men who handle the metal. Printers, type-founders, and 
workers in white-lead are especially liable to be afTected. Oc- 
casionally it results from the use of water which has been 
carried through lead pipes or which has been stored in cisterns 
lined with lead. 

Pathology. — The muscles are degenciatecl, and the pe- 
ripheral nerves frequently reveal evidences of chronic neuritis. 
In cases associated with marked muscular atrophy, polio- 
myelitis is discovered. 

Symptoms. — The following are the chief manifestations : 
Anaemia ; severe colicky pains centering around the umbilicus 
and associated with retraction and rigidity of the abdominal 
walls; constipation; a blue line on the gums near the in- 
sertion of the teeth, due to the deposition of a sulphuret of 
lead ; paralysis ; tremors ; intense headache ; pains in the 



412 DISEASES OP THE NERVOUS SYSTEM. 

joints (arthralgia) ; arteriosclerosis ; chronic interstitial ne- 
phritis ; and grave cerebral symptoms (encephalopathies). 

The Paralysis. — This in most instances involves the exten- 
sors of both forearms, and gives rise to the well-known wrist- 
drop. In advanced cases the muscles atrophy and yield the 
reactions of defeneration. Sensation is not affected. 

Encephalopathies. — These are among the more rare mani- 
festations of plumbism, and consist of convulsions, coma, 
delirium, intense headache, and blindness from atrophy of 
the optic nerves. 

Prognosis. — Guardedly favorable. 

Treatment. — Prophylaxis consists in absolute cleanliness ; 
the use of respirators in lead factories ; the avoidance of 
eating in an atmosphere laden with the dust of the metal ; 
and in the occasional use of Epsom salts. 

The curative treatment consists in the administration of 
iodide of potassium (gr. v-x thrice daily) and the use of 
sulphur baths. Constipation should be relieved by Epsom 
salts. The colic may require the hypodermic injection of 
morphia and atropia, and the application of hot fomentations 
to the abdomen. The paralysis generally yields to massage, 
the constant current, and hypodermic injections of strychnia. 

CHRONIC MERCURIAL POISONING. 

Etiology — This is usually observed in those employed in 
quicksilver mines, or engaged in making mirrors, barometers, 
or other scientific instruments requiring the use of mercury. 

Symptoms. — Anaemia, loss of flesh and strength, gastro-in- 
testinal disturbances, and marked tremors. The latter usually 
begin in the extremities, and are at first slight, but later the 
whole body is involved, and the tremors are violent. In ad- 
vanced cases they may continue during sleep. Grave cerebral 
symptoms occasionally develop, such as vertigo, headache, im- 
pairment of intellect, convulsions, paralysis, and coma. 

Diagnosis. — The history, the marked tremor of the head, 
and the absence of the peculiar gait (festination) will distin- 
guish it from paralysis agitans. 



CHRONIC ARSENICAL POISONING. 413 

The history and the absence of nystagmus will distinguish 
it from disseminated sclerosis. 

Treatment. — Eemoval from the influence of the metal. 
Tonics. Iodide of potassium. Electricity. Sedatives for the 
tremors. 

CHRONIC ARSENICAL POISONING. 

Etiology. — It is observed in workmen employed in arsenic 
works and glass factories. Inhaling the dust of fabrics, 
papers, artificial flowers etc., which have been colored with 
arsenic, may induce poisoning. 

Symptoms. — Anaemia, loss of flesh and strength, conjunc- 
tivitis, gastro-intestinal catarrh, loss of hair, cutaneous erup- 
tions, and paralysis. The last, unlike that observed in lead- 
poisoning, usually involves the extensors of the legs, but later 
it may also involve the arms. 

Treatment. — Removal from the influence of arsenic. 
Tonics. Electricity and massage to the affected muscles. 



DISEASES 



SKIN AND ITS APPENDAGES. 



THE COLOR OF THE SKIN. 

Pallor as a permanent condition is generally an expression of 
anaemia ; but it should be borne in mind that in some eases 
the surface is pale when the blood is normally rich in corpus- 
cles and haemoglobin ; and that in other cases the surface has 
a natural color when the blood is considerably deficient in 
corpuscles and haemoglobin. It follows therefore that an abso- 
lute diagnosis of anaemia must rest on an analysis of the 
blood. 

Pallor as a temporary condition may result from emotional 
excitement, exposure to extreme cold, shock, syncope, or col- 
lapse. 

Yellowness Of the Skin may result from jaundice, in which 
case the conjunctivae will also be yellow and the urine will 
contain bile. Yellowness may also result from chlorosis or 
pernicious anaemia, and in these cases the normal color of the 
conjunctivae, the associated symptoms of the disease, and the 
absence of bile in the urine will indicate the cause. 

Whiteness of the Skin. — A milk-white hue over extensive 
areas may be observed in albinism, vitiligo, and in leprosy. 

Dark-brown or gray discoloration of the skin is observed in 
the following conditions : — 

Addison's Disease, — In this affection the skin has a bronzed 
appearance, which is especially marked on exposed parts ; the 
(414) 



THE COLOR OF THE SKIN. 415 

buccal mucous membrane may also reveal discolored plaques ; 
and there are in addition anaemia, prostration, and gastric 
irritability. 

Argyria. — This term is applied to the dark-gray discolora- 
tion of the exposed parts which follows the prolonged use of 
nitrate of silver. The discoloration is due to a deposition 
of the oxide of silver, and is more or less permanent. It is 
said to be preceded by a dark line on the gums, similar to the 
one observed in chronic lead-poisoning. Formerly, when 
nitrate of silver was used extensively in the treatment of 
epilepsy, it was not an uncommon condition. 

Vagabond ismus. — This term is applied to the dark-brown 
discoloration of the skin which follows prolonged exposure to 
the weather, uncleanliness, and perhaps the irritation of the 
skin resulting from pediculosis. 

Blueness of the Skin, as a permanent condition, is generally 
an expression of cyanosis. 

Hardness, or Induration of the Skin. 

Induration of the skin is observed in scleroderma. In this 
affection the skin is tense, hide-bound, and more or less pig- 
mented. Induration is also observed in myxoedema. In this 
condition the skin is swollen as in oedema, but it is firm, in- 
elastic, and does not pit on pressure. In addition, the features 
are peculiarly broadened and the mental power is impaired. 
Circumscribed patches of induration are observed in morplioea. 
The circumscribed patches, with hypersemic or pigmented 
borders, and the smooth, shiny, atrophied skin are the diag- 
nostic features. 

(Edema, or dropsy of the subcutaneous tissues, when extreme, 
also causes induration. 

A brawny, indurated condition of the muscles, especially of 
the legs, is frequently observed in scurvy. It probably results 
from a sanguineous exudation. The anaemia, purpuric spots, 
and spongy, bleeding gums will aid in the diagnosis. 



416 DISEASES OF THE SKIN AND ITS APPENDAGES. 



(EDEMA, OR DROPSY OF THE SUBCU- 
TANEOUS TISSUES. 

(Edema may be recognized by a swelling which pits on 
pressure. It results from : (1) Venous stasis — from chronic 
heart, liver, and lung disease ; and from local obstruction to 
the venous circulation, as by a tumor, pregnant uterus, or a 
varicose condition of the veins. (2) Alterations in the blood 
or capillaries, as in Bright's disease, anaemia, and inflammation. 

GLOSSY SKIN. 

" Glossy Skin." — This term was applied by Paget to indi- 
cate a smooth, atrophied, and shiny appearance of the skin. 
It is most frequently observed after inflammation or injury of 
the nerve-trunks. It is sometimes associated with an intense 
burning pain, to which Mitchell has given the name causalgia, 

ENLARGEMENT OF THE SUPERFICIAL 
VEINS. 

Enlargement of the superficial veins may result from 
chronic heart, lung, or liver disease ; from the pressure of a 
tumor or aneurism on deep-seated veins ; or, as a general con- 
dition, it may be congenital and result from occlusion of deep 
veins. 

" Caput Medusae." — This term is applied to a circle of dilated 
veins surrounding the umbilicus. It is indicative of obstruc- 
tion to the portal circulation, and may result from atrophic 
cirrhosis of the liver, from thrombosis of the portal vein, or 
from the pressure of a tumor on the portal vein. 

CUTANEOUS EMPHYSEMA. 

Cutaneous emphysema consists in an escape of air into the 
cellular tissue. It is manifested by a diffuse, pallid swelling 
of the skin, which crackles on palpation and which pits on 
pressure ; but, unlike oedema, the depression immediately dis- 
appears when the finger is withdrawn. It may result (1) from 



CUTANEOUS ERUPTIONS. 417 

traumatism of the air-passages, as a gunshot wound of the chest 
or a fracture of the rib. (2) From rupture of the oesophagus, 
stomach, intestines, larynx, trachea, or lungs. The rupture of 
these organs is usually due to ulceration, as in cancer of the 
oesophagus, tuberculous cavity of the lung, or purulent pleurisy ; 
but occasionally the lung ruptures from violent strain. 

ABNORMAL. CONDITIONS OF THE NAILS. 

Atrophy of the Nails.— The nails may become dry, brittle, 
discolored, and cracked in organic disease of the spinal cord ; 
after inflammation or injury of the peripheral nerves ; after 
prolonged febrile diseases, like typhoid fever • and in certain 
affections of the skin which involve the matrix of the nail, as 
eczema, psoriasis, and ringworm. 

Curving of the Nails. — Incurvation of the nails is generally 
associated with clubbing of the terminal phalanges. It is ob- 
served in phthisis, chronic cardiac disease, and in many wast- 
ing diseases. 

Onychia. — Inflammation of the matrix of the nail may re- 
sult from injury ; from syphilis ; from organic disease of the 
spinal cord, as locomotor ataxia ; from arthritis deformans ; 
and from cutaneous affections involving the matrix, as leprosy, 
ringworm, and eczema. 

CUTANEOUS ERUPTIONS. 

Macules. 

Macules are discolored spots which are neither elevated nor 
depressed. 

A general red macular eruption is observed in the following 
conditions : — 

Syphilis. — Secondary syphilis may manifest itself as an 
eruption of small red macules. They are usually abundant 
and frequently cover the entire body ; they lack subjective 
symptoms ; they are usually associated with the history or 
with the evidences of syphilis, such as the scar of the chancre, 
bone-pains, alopecia, swollen glands, and sore throat. 
27 



418 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Erythema Multiforme may manifest itself as a macular 
eruption, but the macules are usually associated with dark-red 
papules or tubercles. The multiformity of the lesions ; their 
preference for the extremities ; their appearance in successive 
crops ; the short duration of each lesion ; the absence of sub- 
jective phenomena, such as itching and burning ; and the 
presence of rheumatic pains are the diagnostic features. 

Pityriasis rosea. — The eruption is especially found on the 
trunk ; the lesions are rose-red in color ; they are slightly 
scaly, the scales being dry ; subjective phenomena are gener- 
ally absent ; and the duration is a few weeks. 

Pediculosis Corporis. — Lice may produce a minute red or 
purple eruption. The small size of the lesions ; their confine- 
ment to the covered parts ; the intense itching and the presence 
of scratch-marks ; and the discovery of pediculi on the clothes 
are the diagnostic features. 

Rotheln. — This affection produces a macular or maculo- 
papular rash which disappears in two or three days by slight 
desquamation. The moderate fever, sore throat, swollen 
cervical glands, and history of contagion will assist in the 
diagnosis. 

Accidental Rashes. — Local inflammation like tonsillitis and 
acute gastritis, and certain drugs and foods occasionally pro- 
duce a macular rash. 

Purpuric spots, or hemorrhagic macules (petechia?), result 
from minute extravasation of blood into the skin. 

A purpuric eruption is observed in the following condi- 
tions : — 

Purpura Hsemorrhagica {Morbus Maculosus WerlhofH). — 
This affection occurs especially in children ; it is associated 
with fever and bleeding from the mucous membranes ; and 
generally runs a course of one or two weeks. 

Scurvy. — This disease results from a deprivation of fresh 
vegetables, and is associated with spongy, bleeding gums, 
great weakness, and a brawny induration of the muscles. 

Rheumatism. — Occasionally an eruption of purpuric spots 
appears in rheumatic subjects. It is usually associated with 
pains in the limbs, but fever is generally absent. 






CUTANEOUS ERUPTIONS. 419 

PeliosiS Rheumatica (Schonlein's Disease). — This is an acute 
affection characterized by purpuric spots, urticaria, sore throat, 
moderate fever, and an inflammation of the joints resembling 
rheumatism. By some the disease is regarded as a manifesta- 
tion of rheumatism. 

Extreme Anaemia. — A petechial rash is not uncommon in 
pernicious anaemia, leucocythsemia, cancer, and advanced 
Bright's disease. The history and the associated symptoms of 
the original disease will indicate the diagnosis. 

Certain Infectious Diseases. — In typhus fever a purpuric 
eruption appears on the fourth or fifth day. In cerebro- 
spinal meningitis the eruption is frequently petechial. In 
malignant measles and malignant smallpox the rash is often 
hemorrhagic. In acute yellow atrophy of the liver and in 
ulcerative endocarditis a petechial eruption is frequently 
observed. 

Poisoning from Certain Substances. — Poisoning from phos- 
phorus, the virus of venomous snakes, mercury, and antipyrin 
may be associated with an eruption of purpura. 

Pediculosis and Kindred Affections.— Body-lice, bed-bugs, 
and fleas produce petechial lesions which are surrounded by 
slight areolae. The itching, scratch-marks, and discovery of 
the parasite are the diagnostic features. 

Brown macules are observed in : — 

Lentigo, or Freckle. — The spots are small, and are found 
especially on exposed parts — face, neck, shoulders, and hands. 

Chloasma. — Dark spots may result from irritation of the 
skin from the action of chemicals, heat, scratches, or blisters. 
They are sometimes noted in general diseases like Addison's 
disease and syphilis. They also occur in primary affections 
of the skin, as vitiligo, morphcea, scleroderma, and leprosy. 

Moles, or Nsevus Pigmentosa. — These consist in congenital 
deposits of pigment on various parts of the body. 

White or pale yellow macules are observed in : — 

Vitiligo. — Apart from the absence of pigment, the skin is 
normal in appearance and function. An excess of pigment is 
generally noted at the periphery of the white patches. 

Leprosy. — In this condition there are structural changes in 
the skin and anaesthesia in addition to the white appearance. 



420 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Morphosa. — In the late stage of this affection the circum- 
scribed patches are white or yellow. The structure of the 
skin is altered, and the periphery of the patches is distinctly 
hypersemic. 

Facial Hemiatrophy. — The onset of this disease may be 
marked by the appearance of a yellow or white spot on one 
side of the face. 

Diffuse Erythema or Inflammation of the Skin. 

Diffuse erythema or inflammation of the skin may result 
from : — 

The Action of Certain Drugs (Dermatitis Medicamentosa). — 
Belladonna, quinine, chloral, cubebs, salicylic acid, and arsenic 
may produce a diffuse red rash. 

Scarlet Fever, — The history of contagion, high fever, sore 
throat, swollen glands, rapid pulse, and the punctiform charac- 
ter of the rash will indicate the diagnosis. 

Rd the 111, — In some cases of rotheln the eruption is red and 
diffuse. The history, slight fever, slight catarrh, and marked 
swelling of the post-cervical glands will suggest rotheln. 

Local irritation from traumatism, excessive heat, poisonous 
plants or drugs. 

Erythema Intertrigo. — This occurs where two cutaneous 
surfaces come in contact. The part is red, moist, and some- 
times macerated. The condition excites a burning pain. 

Eczema. — The skin is thickened and infiltrated; there is 
marked itching ; the redness shades off gradually ; and there is 
no fever. 

Erysipelas. — The part is considerably swollen ; the redness 
and swelling terminate in an abrupt ridge ; and the tempera- 
ture is high. 

Acne Rosacea. — This is a chronic disease ; the redness 
appears on the face, and is associated with acne lesions and 
dilated capillaries. 

Vesicles. 

A vesicle is a small elevation of the skin, containing serous 
fluid, and varying in size from a pinhead to a split-pea. 
Vesicles are observed in the following conditions :— 



CUTANEOUS ERUPTIONS. 421 

Sudamen. — This consists of an eruption of minute vesicles 
which result from the imprisonment of sweat in the layers of 
the skin. It is usually associated with free perspiration ; the 
vesicles are translucent, lack inflammatory characteristics, and 
show no tendency to rupture. 

Herpes. — The vesicles appear in groups or clusters ; they 
are mounted on an inflammatory base ; they show no tendency 
to rupture ; they are frequently associated with burning or 
neuralgic pains ; and they are distributed along the line of the 
nerve-trunks. 

Dermatitis Venanata. — A vesicular eruption may result 
from contact with poisonous plants, such as the poison ivy or 
oak. The eruption generally appears on the exposed parts — 
face or hands ; the part is red and swollen and there is intense 
itching. 

Dermatitis Herpetiformis. — The vesicles are very irregular 
in shape ; they appear in clusters ; they are very tense ; they 
show no tendency to rupture ; they are frequently associated 
with other lesions — papules, pustules, and bulla? ; they excite 
intense itching ; and they appear in crops over a period of 
weeks or months. 

Impetigo Contagiosa. — The eruption consists of small vesi- 
cles which subsequently enlarge until they reach the size of 
blebs ; the vesicles appear iu crops ; are commonly discrete ; 
are flat and umbilicated ; are filled with a straw-colored fluid ; 
they show no tendency to break, but dry up and form thin 
yellow crusts, and they excite but little itching. The 'disease 
is contagious and auto-inoculable ; occurs especially in chil- 
dren ; and lasts from one to two weeks. 

Vesicular Eczema. — The vesicles are quite small and are 
aggregated in patches ; the intervening skin is red and thick- 
ened ; the vesicles tend to break and pour forth a serous fluid 
which keeps the part moist; and the eruption is associated 
with intense itching. 

Miliaria, or Heat-rash. — This may appear as an eruption 
of minute vesicles ; they are alway discrete ; they are sur- 
rounded by red areola? ; they usually appear on the trunk ; 
they are generally associated with pin-head papules ; they 



422 DISEASES OF THE SKIN AND ITS APPENDAGES. 

show no tendency to rupture ; and they excite a little burning 
and itching. 

Scabies. — In this affection the vesicles are small ; they are 
usually associated with pustules and burrows ; they excite in- 
tense itching ; and they are usually found on the hands, fore- 
arms, in the axillae, under the mammae, and on the inner 
aspects of the thighs. 

Blebs, or Bullae. 

A bleb, or bulla, is a circumscribed elevation of the skin, 
containing serous fluid, and varying in size from a pea to an 
egg. Blebs are observed in the following conditions : — 

Impetigo Contagiosa. — The blebs are flat and umbilicated ; 
they contain a straw-colored fluid ; they appear in crops ; they 
are commonly discrete ; they show no tendency to break, but 
dry up and form thin yellow crusts ; and they excite but little 
itching. The disease is contagious and auto-inoculable ; occurs 
especially in children ; and lasts from one to two weeks. 

Dermatitis Herpetiformis The bullae are frequently asso- 
ciated with papules, vesicles, and pustules ; they are surrounded 
by inflamed skin ; they appear in clusters ; they show no 
tendency to break, but dry up and leave yellowish-brown 
crusts ; and they excite considerable itching. 

Pemphigus. — The bulla? appear in crops ; excite but little 
itching ; they lack an inflammatory areola ; and as a rule they 
dry up, and leave behind a thin pellicle. The disease is 
generally chronic. 

Syphilis. — The bullous syphilide is observed in hereditary 
syphilis, and very late in the acquired disease. The contents 
of the bullae soon become pustular; the blebs dry up, and 
form dark-green, cone-shaped, stratified crusts, which become 
detached and leave discharging ulcers. The history and the 
other evidences of syphilis will aid in the diagnosis. 

Pustules. 

A pustule is a small circumscribed elevation of the skin 
containing pus. Pustules are observed in the following dis- 
eases : — 



CUTANEOUS ERUPTIONS. 423 

Eczema Pustulosum, — The pustules are small; are aggre- 
gated in a patch ; are generally associated with minute 
vesicles ; the intervening skin is red and thickened ; and 
there are marked burning and itching. 

Acne Vulgaris. — The pustules are usually confined to the 
face, back, and shoulders ; they have their origin in the 
sebaceous follicles ; they are generally associated with papules 
and comedones ; and they excite no itching. 

Dermatitis Herpetiformis. — The pustules are frequently 
associated with papules and vesicles ; they are surrounded by 
inflamed skin ; they appear in clusters ; and they excite con- 
siderable itching. 

■ Impetigo Simplex. — This affection is usually observed in 
children ; the pustules are round, and range in size from a 
pea to a cherry ; there is only a slight red areola, and this 
finally disappears ; the pustules remain discrete ; they show 
little tendency to rupture, but dry up and form yellowish- 
brown crusts ; they are mostly observed on the extremities ; 
they excite no itching. The disease lasts from a few days to 
a week. 

Impetigo Contagiosa. — The eruption is at first vesicular, but 
it soon becomes pustular; the pustules vary in size from a pea 
to a large marble ; they are flat and umbilicated ; they appear 
in crops ; they are commonly discrete ; they show no tendency 
to break, but dry up and form thin yellow crusts ; and they 
excite but little itching. Tire disease is contagious and auto- 
inoculable ; occurs especially in children ; and lasts from one 
to two weeks. 

Varicella, or Chicken-pox The pustules result from vesi- 
cles ; they appear especially on the trunk ; they are small and 
not umbilicated ; they excite but little itching. There is some 
fever. The disease lasts but three, or four days. 

Ecthyma, — This disease is observed especially in poorly- 
nourished adults. The pustules vary in size from a pea to a 
cherry ; they are few in number ; they are mounted on an 
inflammatory base, and are surrounded by a distinct inflam- 
matory areola ; they excite but little itching ; they seldom 
break, but dry up and form brownish crusts. 



424 DISEASES OF THE SKIH AKD ITS APPENDAGES. 

Smallpox. — In this disease shot-like papules and umbili- 
cated vesicles precede or are associated with the pustules. The 
latter are small, surrounded by a red areola, and usually excite 
some itching. The high fever and history of contagion will 
assist in making the diagnosis. 

Syphilis, — The pustules are frequently associated with other 
lesions ; they are often mounted on a copper-colored inflamma- 
tory base ; they excite no itching ; and they are usually asso- 
ciated with the history and the other evidences of syphilis. 

Scabies. — The pustules are small and usually associated 
with papules, vesicles, and burrows; they are especially ob- 
served on the hands, forearms, in the axillae, under the mam- 
mae, and on the inner aspects of the thighs, and they excite 
considerable itching. There is often a history of contagion. 

Papules. . 

A papule is a circumscribed solid elevation of the skin 
varying in size from a pin-head to a nea. Papules are ob- 
served in the following conditions : — 

Erythema Multiforme. — The papules are often associated 
with macules and tubercles ; they are flat, and are of a bright- 
red or purple color ; they appear especially on the extremities ; 
and they show no tendency to suppurate, but gradually disap- 
pear in the course of two or three weeks ; they excite no 
itching, but they are often associated with prostration and 
rheumatic pains. 

After the Use of Certain Drugs. — Bromides, iodides, 
copaiba, cubebs, and tar may produce a papular eruption. 
The history will aid in the diagnosis. 

Eczema Papulosum. — The papules are very small, closely 
aggregated, and often associated with vesicles and pustules; 
the skin is thickened ; and there is intense itching. 

Miliaria, or Prickly Heat. — The papules are very small ; 
they are very often associated with minute vesicles ; they 
always remain discrete ; they appear especially on the trunk ; 
and they excite a little burning and itching. 

Acne Vulgaris. — The papules are usually confined to the 
face, back, and shoulders; they are generally associated with 



CUTANEOUS ERUPTIONS. 425 

pustules aud comedones ; they involve the sebaceous follicles ; 
and they do not excite subjective symptoms. 

Scabies. — The papules are small and are usually associated 
with pustules, vesicles, and burrows; they are especially ob- 
served on the hands, forearms, in the axilke, under the mam- 
mae, and on the inner aspects of the thighs ; and they excite 
considerable itching. There is often a history of contagion. 

Syphilis. — The papules are dark in color ; they are widely 
distributed, being especially marked on the trunk and flexor 
surfaces of the extremities ; they are usually associated with 
pustules; and they excite no itching. The history and the 
accompanying evidences of syphilis will aid materially in 
establishing the diagnosis. 

Smallpox. — The papules are hard and have a shot-like feel ; 
they soon terminate in umbilicated vesicles ; they excite some 
itching, and they are associated with high fever, pain in the 
back, and often a history of contagion. 

Measles. — The papules are small, and run together to form 
crescentic-shaped patches ; and they are associated with mod- 
erate fever, swollen cervical glands, coryza, conjunctivitis, and 
bronchitis. There is often a history of contagion. 

Tubercles. 

Tubercles are large, circumscribed, solid elevations of the 
skin varying in size from a large pea to a walnut. They are 
observed in the following conditions : — 

Erythema Nodosum.— The tubercles are large ; they usually 
appear on the extremities ; they are reddish-purple in color ; 
they never suppurate ; and they are associated with malaise, 
fever, and rheumatic pains. 

Erythema Multiforme. — The tubercles are generally asso- 
ciated with macules and papules ; they are flat, and are of a 
bright-red or purple color ; they appear especially on the ex- 
tremities, and they show no tendency to suppurate, but gradu- 
ally disappear in the course of two or three weeks. They 
excite no itching, but are often associated with prostration and 
rheumatic pains. The disease is probably allied to erythema 
nodosum. 



426 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Lupus Vulgaris, — This may begin as a papule or tubercle. 
It is especially observed on the face. The tubercles are of a 
pale-red color and are quite soft to the touch. As a rule, 
they slowly break down and form shallow ulcers with soft red 
margins. The ulcers are painless and secrete but little ma- 
terial. They may invade all of the soft structures, but the 
bones escape. 

Syphilis. — The tubercular syphilide manifests itself as dark- 
red tubercles. There are seldom more than three or four, and 
they generally appear on the face and extremities. They are 
very firm, and often break down, forming deep, punched-out 
ulcers which secrete an abundant purulent material. 

Tinea Sycosis, or Barber's Itch. — The tubercles appear on 
the hairy parts of the face and involve the hair-follicles. Sup- 
puration soon begins in the centre of the tubercles, and the 
hairs become dry, brittle, and loose. The microscope will re- 
veal the tricophyton. 

Leprosy. — One form of leprosy manifests itself as tubercles. 
The latter are of a pale-red or yellow color, and undergo slow 
absorption or ulceration. There is usually more or less anaes- 
thesia in the parts affected. 

Wheals, or Pomphi. 

Wheals are evanescent elevations of the skin, generally 
more or less round, and often white in the centre and pale-red 
at the periphery. They excite considerable itching. They 
are observed in the following conditions : — 

Urticaria. — The wheals appear in crops ; they are of very 
short duration ; they may appear on any part, of the body ; 
and they excite intense itching. 

Erythema multiforme, peliosis rheumatica (Schonlein's dis- 
ease), and certain insects like mosquitoes also produce wheals. 

Crusts. 

Crusts consist in dried exudation, and may be red, yellow, 
brown, or green in color. They are marked in the following 
diseases : — ■ 



CUTANEOUS ERUPTIONS. 427 

Eczema. — The crusts are generally associated with pustules 
and vesicles ; the surrounding skin is red and thickened ; and 
there is considerable itching. 

Seborrhea. — Crusts of seborrhoea are generally observed 
on the scalp. Itching is absent, and there are no evidences of 
inflammation. 

Syphilis. — The crusts are thick ; they are of a dark-brown 
or green color ; and they are often associated with ulcers 
which freely discharge. The history and other evidences of 
syphilis will aid in the diagnosis. 

Impetigo. — The crusts are thin and yellow ; and they are 
associated with blebs which appear in crops. 

Favus. — The crusts generally appear on the scalp ; they are 
yellow, brittle, and cup-shaped ; they are usually perforated 
by a hair, and have a peculiar musty odor. 

Tinea Tonsurans, or Ringworm of the Scalp. — In neglected 
cases this affection may be associated with crusting. It is 
only observed in children. The grayish scales, the dry, brittle, 
and broken hairs projecting through the crusts, the alopecia, 
and the detection of the tricophyton are the diagnostic 
features. 

Scales. 

Scales are dry exfoliations from the upper layers of the skin. 
They are observed in the following diseases : — 

Squamous Eczema. — The scales are usually associated with 
papules ; the underlying skin is red and thickened ; and there 
is often marked itching. 

Seborrhea Sicca. — The scales are greasy, and the under- 
lying skin shows no evidence of inflammation. The sebaceous 
follicles are often dilated. 

Psoriasis. — The scales are dry, and are of a pearly- white 
color ; they are associated with circumscribed, sharply-defined, 
elevated inflammatory patches. The extensor surfaces are 
especially involved. There is little or no itching. 

Ichthyosis. — This affection begins in early life. The scales 
are dry, and are especially marked on the extensor surfaces. 
Itching is absent, and there is no evidence of inflammation. 



428 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Syphilis. — The scales are dry, and are of a grayish color ; 
they are usually associated with papules ; and they are espe- 
cially marked on the palms and soles. There is no itching. 
The history and other evidences of syphilis will assist in the 
diagnosis. 

Pityriasis Rosea. — The scales are found especially on the 
trunk, aud are associated with small, rose-red macules. There 
is no itching. The disease runs an acute course of a few weeks' 
duration. 

Ringworm. — The scales are dry aud scant ; they are associ- 
ated with circumscribed red patches which tend to disappear 
in the centre. There is often marked itchiug. Microscopic 
examination reveals the tricophyton. 

Ulcers. 

Ulcers are observed especially in the following diseases : — 

Syphilis. — The ulcers are deep ; they have a punched-out 
appearance ; they secrete an abundant offensive material ; they 
often involve the bone ; they extend rapidly ; they are not 
painful, and the imperfect cicatrix which they produce is soft. 
The history and other evidences of syphilis will aid in the 
diagnosis. 

Epithelioma. — This appears in late life ; there is usually a 
single centre of ulceration ; the ulcer is irregular iu shape ; 
the edges are thickened and infiltrated ; the secretion is scanty 
and bloody ; the progress is somewhat slow, and there is often 
pain. 

Lupus Vulgaris. — This generally appears in early life ; there 
are often several centres of ulceration ; the ulcers are usually 
superficial ; the edges are not thickened ; the progress is ex- 
tremely slow ; the bones are never involved ; there is very 
little secretion, and soft papules often develop in the cicatrix, 
which is firm and contracted. 

Simple Ulcers may result from traumatism, the application 
of caustics, or the action of intense heat or cold. Ulcers are 
frequently observed on the legs of old people in association 
with varicose veins. Simple ulcers may be recognized by the 
history, location, appearance, and the absence of other causes. 






CUTANEOUS ERUPTIONS. 429 

Perforating Ulcer of the Foot. — This term is applied to a 
deep-seated ulcer appearing on the sole of the foot and most 
frequently observed in locomotor ataxia. It usually begins as 
a corn in the neighborhood of the great toe, and is generally 
associated with anaesthesia of the sole of the foot. 

Decubitus. — This term is applied to the bedsores which 
form after the occurrence of grave cerebral or spinal lesions. 
They are generally observed on parts which are subjected to 
pressure, as the sacrum, buttocks, calves, and heels, and are 
preceded by erythema and vesication. 



430 DISEASES OF THE SKIN AND ITS APPENDAGES. 

DISEASES OF THE SWEAT-GLANDS. 
Anidrosis. 

Definition. — A deficiency of sweat. 

Etiology. — It may he a symptom of some general disease, 
like diabetes or Bright' s disease ; it may be an associated con- 
dition in certain cutaneous diseases, such as ichthyosis or psori- 
asis ; and it may develop without obvious exciting cause as a 
result of disturbed innervation. 

Treatment. — Remedies should be directed to the primary 
disease. 

Hyperidrosis. 

Definition. — Excessive sweating. 

Etiology. — As a general condition it is often observed in 
phthisis and in other diseases characterized by marked de- 
bility. Local hyperidrosis is most frequently observed in the 
hands, feet, and axillae, and probably results from some de- 
rangement of the sympathetic nervous system. Unilateral 
sweating of the face may indicate an aneurism or tumor 
pressing on the cervical sympathetic. 

Symptoms. — The primary symptom is excessive sweating, 
and this often leads to intertrigo or eczema. Bromidrosis is 
often associated with the hyperidrosis. 

Prognosis. — Guarded. In many cases the condition is 
very obstinate. 

Treatment. — Frequently there is an evident impairment 
of the general health which will require appropriate treat- 
ment. Internally, one of the following remedies may be em- 
ployed to diminish the amount of sweat : Belladonna, picro- 
toxin, agaricin, or ergot. 

Local Treatment. — Dusting-powders of starch, talc, or ly co- 
podium with boric or salicylic acid ; or lotions containing 
sulphate of zinc, tannic acid, or alum, are often very useful. 

J$l Pulv. acid, salicylic, 
Pulv. zinci carb. prsecip., 
Pulv. magnesii ustse, aa 3iv ; 
Pulu. amyli, gxv ; 

Pulv. talci, 3xx.— M. (Hard a way.) 
Sig. — Dusting-powder. 



DISEASES OF THE SWEAT-GLANDS. 431 

In hyperidrosis of the feet the method suggested by Hebra 
is often very efficient. The feet should be washed, thoroughly 
dried, and then carefully enveloped in strips of musliu which 
have been spread with diachylon ointment. The application 
should be made twice daily. In the dressing no water should 
be employed, but the feet must be carefully wiped and then 
dusted with starch or lycopodium before the ointment is re- 
applied. The treatment should be continued for from one to 
two weeks, after which the feet may be washed and the dust- 
ing-powder alone used 

Bromidrosis. 

(Osmidrosis.) 

Definition. — A functional affection characterized by the 
excretion of sweat which has a fetid odor. 

Symptoms. — It is generally local and often confined to the 
feet ; it is frequently associated with hyperidrosis. 

Treatment. — Same as hyperidrosis. 

Chromidrosis. 

Definition. — A functional affection characterized by the 
secretion of colored sweat. 

Symptoms. — The parts most frequently affected are the face 
and trunk ; the most common colors are red and yellow. It 
is often associated with hyperidrosis. 

Sudamen. 

Definition. — A cutaneous affection characterized by the 
eruption of minute vesicles resulting from the retention of 
sweat in the layers of the skin. 

Etiology. — It is often observed in health in persons who 
perspire freely. It is frequently noted in febrile diseases 
which are associated with sweating, like pneumonia and 
typhoid fever. 

Symptoms. — Minute, irregular, translucent vesicles appear 
on the surface. They are not surrounded by an inflammatory 



432 DISEASES OF THE SKIN AND ITS APPENDAGES. 

areola. They do not rupture, but dry up and are followed by 
slight desquamation. 

Treatment. — The affection has little significance and treat- 
ment is rarely required. 

FUNCTIONAL DISEASES OF THE SEBACEOUS 
GLANDS. 

Seborrhcea. 

(Steorrhoea.) 

Definition. — A functional affection characterized by ex- 
cessive secretion of sebaceous material which may be normal 
or perverted. 

Etiology. — In many cases the cause is not apparent. 
Often the disease is associated with impairment of the general 
health. By some it is regarded as of parasitic origin. 

Varieties. — Seborrhoea sicca and seborrhcea oleosa. 

Seborrhea Sicca. — This form is most frequently observed 
on the scalp and constitutes what is popularly termed dan- 
druff. Examination reveals an incrustation composed of thin, 
yellowish-gray, greasy scales. In uncomplicated cases the 
skin is pale, but from irritation it may subsequently become 
hypersemic or inflamed. When allowed to continue, the 
nutrition of the hair is interfered with and baldness results. 

On the body seborrhoea sicca appears as yellowish-gray 
slightly elevated patches covered with greasy scales. The out- 
lets of the follicles are often dilated. There is generally more 
or less redness of the skin from hyperemia (seborrheal eczema.) 

Seborrhoea Oleosa, — This form is most commonly observed 
on the face, particularly about the nose, which is habitually 
bathed in an oleaginous material which has exuded from the 
sebaceous follicles. Erom irritation the parts are often red. 
The condition is frequently associated with seborrhcea sicca, 
comedo, and acne. 

Diagnosis. Eczema. — In this disease the skin is red and 
thickened ; there is marked itching ; and the scales are not 
greasy. 



COMEDO. 433 

Psoriasis. — In this disease the scales are dry and pearly and 
there are evidences of inflammation. 

Prognosis. — Favorable under prolonged and judicious 
treatment. 

Treatment — The general health may be impaired ; hence 
tonics like iron, strychnia, and cod-liver oil are often indicated. 
The gastro-intestinal tract will often require especial atten- 
tion. Constipation should be relieved by diet, enemata, or 
mild laxatives. 

Local Treatment. — Crusts should be removed by applications 
of oil, followed by shampooing with alcohol and green soap. 
When the scalp is thoroughly clean, one of the following 
remedies may be applied : Sulphur, mercury, tar, carbolic acid, 
or resorcin. 

J$l Sulphur, loti, gij ; 

Balsami Peruviani, gss ; 
Vaselini, ^x.— M. (G. H. Fox.) 
Sig. — After bathing the part apply the ointment. 

Or— 

fy. Acid, carbolic, Tftxxx ; 
Olei ricini, f ^ij ; 
Alcoholis, f ^j-^vj.— M. 

(Duhrestg and Stel wagon.) 
Sig. — Fill an eye-dropper, introduce between the hairs, and sub- 
sequently rub in by means of a flannel rag. 

Mild cases of facial seborrhoea often yield to the following 
ointment : — 

ty Hydrarg. chlor. mit., gr. xx ; 
Ung. zinc, oxid., ^j. — M. 
Sig. — Apply at bedtime. 

COMEDO. 

Definition. — A functional disease of the sebaceous glands, 
characterized by the retention of discolored sebaceous material 
in the distended ducts of the gland. 

Etiology. — It is most frequently observed in young adults. 
Debility, gastro-intestinal disorders, anaemia, and lack of 
cleanliness are predisposing factors. 
28 



431 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Pathology. — The material in the ducts is composed of 
sebum, altered epithelium, and pigment matter which is prob- 
ably derived from without. Microscopic examination of the 
material often reveals a mite — the demodex folliculorum — but 
its presence is accidental and of no etiological significance. 
Comedo is generally associated with seborrhcea. 

Symptoms. — The disease is characterized by an aggregation 
of minute black or yellowish spots which correspond to the 
outlets of the sebaceous glands. The lesion is often slightly 
elevated, and when the skin is squeezed a white filiform mass 
exudes, to which the .term " flesh-worm" has been popularly 
applied. The parts most commonly affected are the face, back, 
and ears. The condition frequently excites an inflammation 
of the follicles, hence it is often associated with acne. 

Prognosis. — Favorable under persistent and judicious 
treatment. 

Treatment. — Anaemia, dyspepsia, and constipation must 
be treated by a careful regulation of the personal hygiene, and 
by the use of appropriate remedies. Tonics like iron, quinine, 
cod-liver oil, and strychnia are often indicated. 

Local Treatment — Large plugs may be pressed out by 
means of a watch-key or a special instrument for the purpose. 
Softening and removal of smaller plugs may be hastened by 
the application of cloths wrung out in very hot water. Kneed- 
ing and the application of alcohol and green soap will also 
assist in their expulsion. Mercury and sulphur are useful 
remedies. 

]£ Hydrarg. chlor. corros., gr. iv ; 
Alcoholis, fgj ; 

Aquse rosse, q. s. ad f^iv.— M. 
Sig.— Dab on twice daily. 

MILIUM. 

(Gmtum.) 

Definition. — An affection characterized by the appearance 
of small, pearly, non-inflammatory elevations, which result 
from the accumulation of inspissated sebum in ducts, the out- 
lets of which have been occluded. 



STEATOMA ERYTHEMA SIMPLEX. 435 

Symptoms. — It is generally observed about the face, and 
consists of a collection of small, round, pearly elevations, which 
vary in size from a pin-head to a small pea. The contents of 
the distended duct cannot be squeezed out until an opening is 
made, and thus it differs from comedo. It is frequently asso- 
ciated with comedo and acne. 

Treatment. — Incise the lesion, express the contents, and 
treat as in seborrhoea. 

STEATOMA. 

(Wen.) 

Definition. — A steatoma, or wen, is a cyst resulting from 
the retention of secretion in a sebaceous gland. 

Symptoms. — One or more rounded or oval elevations, vary- 
ing in size from a pea to a large walnut, slowly appear on the 
scalp, face, or back. They are painless, rather soft, and when 
opened are found to contain a yellowish-white caseous mass. 

Diagnosis. Fatty Tumors. — Fatty tumors are rare on the 
scalp ; they are frequently lobulated ; they have a doughy 
feel ; and are not so movable as wens. 

Treatment. — The sack and its contents should be carefully 
dissected out. Simple excision and evacuation are always fol- 
lowed by a return of the cyst. 

ERYTHEMA SIMPLEX. 

Definition. — Active hyperemia of the skin. 

Etiology. — It may result from exposure to heat or cold ; 
from traumatism ; or from the application of some irritating 
substance. A symptomatic variety is frequently observed in 
gastric irritation and systemic diseases. 

Symptoms. — Diffuse uniform redness, disappearing on pres- 
sure, and without thickening or elevation of the skin. When 
it is marked, there may be slight burning. 

Treatment. — Sedative lotions or dusting-powders. 



436 DISEASES OF THE SKIN AND ITS APPENDAGES. 

ERYTHEMA INTERTRIGO. 

(Chafing.) 

Definition. — Hyperemia induced by the attrition of op- 
posing surfaces of the skin. 

Etiology. — It is common in children and in fat subjects. 
It is especially noted where there are friction and perspiration, 
as under pendulous mammae, between the upper parts of the 
thighs, aud around the genitalia. 

Symptoms. — It is characterized by diffuse redness, and 
often by heat and moisture. It excites a burning sensation. 
When the cause is continued it may result in dermatitis. 

Treatment. — Apply a lotion of boric acid and follow with 
a dusting-powder. 

ERYTHEMA NODOSUM. 

(Dermatitis Contusiformis.) 

Definition. — An acute inflammatory disease, characterized 
by crops of large bright-red nodes which in the process of evo- 
lution assume different colors as in the fading of a bruise. 

Etiology. — Unknown 

Symptoms. — There is a sudden eruption of bright-red 
nodes varying in size from a pea to an egg. The extremities 
are most commonly affected. The advent is marked by 
malaise, headache, slight fever, and rheumatoid pains. At 
first the lesions resemble boils, but unlike the latter, they do 
not suppurate, bat gradually turn yellow, blue, and green as a 
bruise. 

Prognosis. — Favorable. Duration a few weeks. 

Treatment. — Iodide of potassium and alkalies have been 
recommended. Locally, lead-water and laudanum make a 
soothing application. 

ERYTHE3IA MULTIFORME. 

Definition. — An inflammatory disease characterized by 
erythematous, papular, vesicular, or bullous lesions. 



URTICARIA. 437 

Etiology. — It is more common in women than in meD. 
It is apt to develop in the spring or fall. Rheumatism and 
gastro-intestinal disturbances seem to predispose. 

Symptoms. — It is marked by an eruption, usually on the 
extremities, of the following lesions : macules, papules, vesicles, 
or bullae. The lesions may aggregate or remain discrete ; they 
last one or two weeks and gradually fade. There is little or 
no itching. In some cases there is decided constitutional dis- 
turbance, manifested by malaise, headache, slight fever, and 
rheumatic pains. 

Diagnosis. Dermatitis Herpetiformis. — The marked 
itching, the greater tendency for the lesions to cluster, and the 
chronic character of dermatitis herpetiformis will usually pre- 
vent an error in diagnosis. 

Urticaria. — In this disease the individual lesions last a very 
short time and are associated with marked itching. 

Prognosis. — Favorable. Duration a few weeks. 

Treatment. — In the debilitated iron and quinine are useful. 
In the rheumatic, the salts of lithium and of potassium may 
be employed. Constipation should be relieved by saline laxa- 
tives. Locally, lotions of boric or carbolic acid followed by 
dusting-powders exert a beneficial effect. 

URTICARIA. 

(Hives, Nettle Rash.) 

Definition. — An inflammatory affection characterized by 
the eruption of pale-red, evanescent wheals which are asso- 
ciated with severe itching. 

Etiology. — Gastro-intestinal disturbances, emotional ex- 
citement, and chronic visceral diseases predispose. In some 
it may be excited by certain articles of food such as shell- 
fish, strawberries, etc. The bites of certain insects produce the 
disease, such as mosquitoes, bed-bugs, and caterpillars. Some 
drugs induce urticaria in susceptible people. 

Pathology. — The disease consists in a vaso-motor spasm, 
followed by paresis of the vessels and an outpouring of serum. 

Symptoms. — There is a sudden general eruption of papules 
or wheals which is associated with intense itching. Each 



438 DISEASES OF THE SKIN AND ITS APPENDAGES. 

lesion lasts a few hours and is succeeded by new ones in other 
places. 

Varieties. Urticaria Papulosa. — In this form the wheal 
is followed by a lingering papule which is attended by consid- 
erable itching. It is most commonly observed in debilitated 
children. 

Urticaria Hemorrhagica. — The lesions are infiltrated with 
blood. 

Diagnosis. Erythema Multiforme and Erythema Nodo- 
sum. — In both of these affections the lesions last much 
longer, and are free from itching. 

Prognosis. — Unfavorable. In some cases it tends to 
become chronic. 

Treatment. — The cause should be removed when possible. 
In gastric irritation bismuth, or calomel and soda are useful. 

When there is constipation a saline laxative may prove very 
efficient. The special remedies usually recommended are alka- 
lies, salicylate of sodium, quinine, iodide of potassium, and 
atropine. 

Locally, lotions of water and alcohol, carbolic acid, boric 
acid, or hydrocyanic acid are very useful : 

fy. Acid, carbolic, 3J-31J ; 
Glycerin se, f§ss ; 
Alcohol., f^vj ; 
Aquse, q. s. ad Oj.— M. 

Urticaria Pigmentosa. 

This is a form of urticaria observed in young children. It 
is characterized by an eruption of wheals which are itchy and 
persistent, and which leave behind a yellowish or brownish 
pigmentation. The disease runs a chronic course of months or 
years. 



HERPES SIMPLEX. 

(Fever Blisters.) 






Definition. — An acute non-contagious disease, character- 
ized by groups of small vesicles mounted on inflammatory 



HERPES ZOSTER. 439 

Etiology. — Herpes is very common in febrile diseases, 
especially pneumonia, influenza, malaria, and cerebro- spinal 
meningitis. Local irritation also predisposes to it. It is de- 
pendent upon neurotic disturbance. 

Symptoms. — One or more clusters of small vesicles appear, 
usually on the face or genitalia. The vesicles are mounted on 
an inflammatory base, contain clear fluid, and show no ten- 
dency to rupture, Soon their contents become puriform, dry 
up, and form reddish-brown crusts which fall off in a few 
days. Burning and tingling precede and accompany the 
eruption. 

Varieties. — When it appears on the face, it is termed 
herpes facialis ; on the genitals, herpes progenitalis. 

Diagnosis. — Herpes progenitalis must be distinguished 
from chancroid. The history, the superficial character of the 
lesion, the burning pain, and the subsequent course will indi- 
cate herpes. 

Treatment. — The lesion may be painted with flexible 
collodion, or the following lotion employed : — 

]£ Zinc, oxid., gr. xv ; 
Glycerine, 1TL xv ; 
Liq. pluinbi subacetat. dil., TTl x ; 
Liq. calcis, 3vj-^j.— M. (Tilbury Fox. ) 
Sig. — Apply locally. 

HERPES ZOSTER. 

(Zona, Shingles.) 

Definition. — An acute inflammatory disease characterized 
by groups of small vesicles mounted on inflammatory bases, 
associated with neuralgic pain, and following the distribution 
of certain nerve-trunks. 

Etiology. — The disease commonly depends upon a periph- 
eral neuritis. Injury, exposure to cold, and damp clothes 
predispose to it. 

Symptoms. — Clusters of vesicles mounted on inflammatory 
bases may appear on any part of the body ; but they are most 
frequently observed along the course of the intercostal nerves. 
Only one side is affected. Sharp neuralgic pain precedes and 
accompanies the eruption. The fluid in the vesicles soon be- 



440 DISEASES OF THE SKIN AND ITS APPENDAGES. 

comes turbid, dries up, and forms yellowish-brown crusts 
which fall off in a few days. 

Prognosis. — Favorable. 

Treatment. — Tonics are often indicated. Bulkley recom- 
mends phosphide of zinc in doses of one-third of a grain every 
three hours. Morphia is sometimes required for the relief of 
pain. 

Locally. — Sedative applications are required ; the best are 
flexible collodion with morphia, or a solution of menthol or 
carbolic acid, followed by a dusting-powder of oxide of zinc 
or starch. 

fy_ Morph. sulph., gr. viij ; 
Collodii, fiJ.-M. 
Sig. — Apply with a camel's-hair brush. 

HERPES IRIS. 

Definition. — An inflammatory disease, characterized by 
groups of vesicles arranged in concentric rings which present 
a somewhat variegated appearance. 

Etiology. — The causes are unknown. The disease is rare. 

Symptoms. — One or more rings of vesicles successively 
appear around a central vesicle or papule. The different ages 
of the rings which compose the patch impart to the latter a 
variegated appearance. Burning and itching are often atten- 
dant symptoms. The hands, arms, and feet are the parts most 
frequently affected. The lesions appear in successive crops 
over a period of several weeks. In some instances the vesicles 
are quite large and resemble the blebs of pemiphigus. 

Prognosis. — Favorable, but recurrent attacks are common. 

Treatment. — The same as in herpes zoster. 

ACKE. 

(Acne Vulgaris.) 

Definition. — An inflammatory disease of the sebaceous 
glands, characterized by papules and pustules and usually 
seated on the face or back. 



ACNE. 441 

Ettoeogy. — It generally develops about puberty. Anaemia, 
menstrual disorders, and gastro-intestinal disturbances predis- 
pose. Certain drugs like iodide and bromide of potassium 
and copaiba may induce the disease. 

Pathology. — Acne lesions result from the irritation ex- 
cited by retained sebaceous matter, hence the papules and pus- 
tules are commonly associated with blackheads, or comedones. 

Symptoms. — An aggregation of small papules, pustules, 
and comedones about the face, chest, and shoulders. Pustules 
or papules predominate according as the disease is acute or 
chronic. New lesions develop as the old disappear, so that 
the disease usually runs a protracted course. Subjective phe- 
nomena are absent. 

Varieties. Acne Papulosa. — In this form the lesion 
reaches the papular stage and advances no further. 

Acne Pustulosa. — In this variety the papules develop into 
pustules. 

Acne Indurata. — The inflammation is deeply seated, the base 
of the papule or pustule is firm, and the lesion is sluggish. 

Acne Atrophica. — In this form the lesions are followed by 
small scars or pits. 

Acne Hypertrophica. — In this form there is an overgrowth 
of connective tissue and the skin becomes thickened. 

Diagnosis. — The distribution, the chronic character of the 
affection, the involvement of the sebaceous glands, and the as- 
sociation with comedones are the diagnostic features which 
separate acne from all other affections. 

Prognosis. — Curable under persistent treatment. 

Treatment. — The general health must be improved. The 
diet should be nutritious, but easily assimilable; rich food must 
be prohibited. Constipation should be relieved by mild laxa- 
tives. In the anaemic and debilitated iron, quinine, strychnia, 
and cod-liver oil are useful remedies. The special drugs which 
have been recommended are arsenic, ergot, and calx sulphurata. 
Arsenic is best suited to the sluggish indurated forms ; and 
calx sulphurata (gr. yV'i four times daily) to the pustular 
variety. 

Local Treatment. — In the acute form mild applications 
should be employed, like the following calamine lotion : — 



442 DISEASES OF THE SKIN AND ITS APPENDAGES. 

1£ Pulv. zinc, oxid., giij ; 
Pulv. calamine, ^ij ; 
Glycerinse, f^ij ; 
Aquse calcis, f^vj. — M. 

In chronic cases the sebaceous plugs should be removed by a 
watch-key and the pustules incised. Thorough washing with 
very hot water and green soap is also advisable. The best 
local remedies are sulphur, mercury, and resorcin. 

$. Calcis, ^ss ; 

Sulphur, subliraat., ^j ; 
Aquse, ^x.— M. ( Yleminckx. ) 
Evaporate to six ounces and filter. 

Sig. — Apply at first well diluted and gradually increase the 
strength. 

Or— 

}$_ Sulphur, praecip., gj ; 

Ung. aquae rosse, 

Ung. petrolei, aa giv. — M. (Yan Haklingen.) 
Sig. — Apply night and morning. 

Or— 

J$l Hydrarg. ammoniat., gr. xx-xl ; 
Ung. aquce rosae, ^j. — M. 
Sig. — Use night and morning. 

Or— 

I£ Ammon. sulphoichthyol. , 
Aquae destillat., 
Glycerinae, 

Dextrini, aa 33. — M (Unna.) 
Sig. — Use locally. 

ACNE ROSACEA. 

Definition. — A chronic affection, usually located on the 
face in the region of the nose, and characterized by marked 
hyperemia, dilatation of the vessels, overgrowth of tissue, and 
acne lesions. 

Etiology. — Anaemia, menstrual disorders, gastric disturb- 
ances, exposure to extremes of temperature, and intemperance 
are the usual predisposing causes. 

Symptoms. — The affected area is of a deep-red color ; the 
vessels are dilated ; the skin is thickened and lumpy, and 



FURUNCULUS. 443 

acne lesions coexist. In advanced cases the nose may become 
extremely large and lobnlated (Rhinophyma). 

Subjective phenomena are generally absent. 

Diagnosis. Lupus Vulgaris. — In this disease there are 
soft pale-red papules, ulceration, and cicatrization, and no en- 
largement of the bloodvessels. 

Prognosis. — Unless the hypertrophy is marked, the dis- 
ease is curable under protracted treatment. 

Treatment. — The general treatment is the same as in acne 
vulgaris. 

Local Treatment. — Sulphur and mercury are the most reli- 
able remedies. Vleminckx's solution is very useful. Dilated 
vessels should be destroyed by electrolysis. Large hypertro- 
phies may be removed by the knife. 

FURUNCULUS. 

(Boil.) 

Definition. — A miniature dermal abscess. 

Etiology. — Single boils are usually due to local irritation. 
Their appearance in crops (Furunculosis) is usually indicative 
of impaired health. The entrance of pus cocci into the skin 
is always essential to their production. 

Diagnosis. — Furuncles must be distinguished from carbun- 
cles ; the latter are single, large, flattened at their summits, and 
have multiple openings. 

Treatment. — In furunculosis the cause should be searched 
for and, if possible, removed. Tonics like iron, quinine, cod- 
liver oil, and hypophosphites are often very useful. Calx 
sulphurate (tV~6" & r - thrice daily after meals) sometimes proves 
serviceable. A solution of boric acid or of corrosive sublimate 
may be applied locally. The following paste will often abort 
them : — 

Ichthyol, 

Ung. hydrarg., 
Ext. belladonna, aa ^j. — M. 
Sig. — Apply locally and make pressure with strips of adhesive 
plaster. 



444 DISEASES OF THE SKIN AND ITS APPENDAGES. 

CARBUNCULUS 

(Anthrax.) 

Definition. — A circumscribed inflammation of the skin 
and deeper tissues, characterized by a dark-red, painful node 
which breaks down and evacuates through several apertures. 

Etiology. — Lowered vitality from any cause predisposes. 
They are especially common in diabetes. The exciting cause 
is a special microbe. 

Symptoms. — A dark -red, painful, flattened node appears 
surrounded by a dusky-red area of induration. In a week or 
ten days suppuration begins, and the contents are discharged 
through several orifices. There is generally marked con- 
stitutional disturbance. The most common seats are the nape 
of the neck, back, and buttocks. 

Prognosis. — Guardedly favorable. Death is not an in- 
frequent termination in the old and debilitated. 

Treatment. — Generally tonics like quinine, iron, and 
whiskey are indicated. Opium may be required to relieve 
pain. 

Local Treatment. — In the early stage they may be aborted 
by a central injection of ten to twenty minims of a 5 or 10 per 
cent, solution of carbolic acid in glycerine. When not seen 
until abortion is too late, firm compression may be made by 
straps applied concentrically, leaving the central orifice free 
for the discharge of sloughs ; an antiseptic dressing may be 
applied over the straps. 

PSORIASIS. 

Definition. — A chronic inflammatory disease, character- 
ized by red, scaly, sharply-circumscribed, elevated lesions. 

Etiology. — Psoriasis usually develops in young adults. 
Heredity, the gouty diathesis, pregnancy, and lactation seem to 
predispose. It is as common in the robust as in the debilitated. 
It is non-contagious. 

Pathology. — A localized hypertrophy of the rete mucosum 
associated with inflammation. 






psoriasis. 445 

Symptoms. — Little red spots appear on the body, and 
gradually grow until they reach the size of a dollar. The 
lesions are of a dull pink or red color, sharply defined, some- 
what elevated, surrounded by healthy skin, and covered with 
abundant dry, pearly, overlapping scales. These scales are 
readily detached, leaving behind a dry, slightly excoriated 
surface. The lesions may be uniformly distributed over the 
entire body, but usually the extensor surfaces are more affected ; 
a symmetrical arrangement is often observed. Itching is 
slightly or entirely absent. After a variable time the centre of 
the patch disappears and leaves behind a spot of healthy skin 
which gradually increases until no trace of the lesion remains. 
The disease runs a protracted course of months or years, im- 
proving in the summer and growing worse in the winter. 

Diagnosis. Eczema. — In this disease the patches are not 
sharply defined, but shade off gradually into the surrounding 
skin ; there is marked itching ; there is usually a decided dis- 
charge, and healing begins at the periphery instead of at the 
centre as in psoriasis. 

Seborrhoea. — In this affection the lesions are usually confined 
to the scalp and face, while psoriasis is general ; the scales are 
gray and greasy ; the patches are not circumscribed, and lack 
the inflammatory character of psoriasis. 

Papulosquamous Syphiloderm. — The history, the associated 
symptoms of syphilis, the coppery color of the lesions, the 
scant scaling, the special tendency to involve the hands and 
soles will render the diagnosis apparent. 

Prognosis. — The disease disappears under treatment, but 
relapse generally follows after a longer or shorter period. 

Treatment. — The general health may require attention. 
In the gouty alkalies are of value ; and in the anaemic iron and 
cod-liver oil are indicated. Arsenic is often of considerable 
value ; it should be given in small doses cautiously increased. 
Iodide of potassium (gr. x-xx thrice daily) is sometimes rec- 
ommended. 

Local Treatment — The scales should be removed by alkaline 
baths before local applications are made. The best local 
remedies are tar, chrysarobin, salicylic acid, resorcin, sulphur, 
and ammoniated mercury. 



446 DISEASES OF THE SKIN AND ITS APPENDAGES. 

I£ Acid, ehrysophanic, gr. x; 

Adipis benzoat., 3j. — M. 
Sig. — Apply twice daily. 

Or— 

J$l Sulphur, sublimat., 
Ol. cadini, aa £iv ; 
Sapon. virid., 
Adipis, aa ^j ; 
Cretan praep., gijss. — M. (Wilkinson.) 

ECZEMA. 

(Tetter.) 

Definition. — A non-contagious inflammatory disease of 
the skin, characterized by multiform lesions — erythema, pap- 
ules, vesicles, pustules, scales, and crusts — and associated with 
infiltration, itching, and more or less discharge. 

Etiology. — It is most common in the young and in the 
aged. Digestive disturbances, debility, gout, and rheumatism 
predispose to its development. It may be due to external 
irritants like cold, heat, the rhus-plant, hard soaps, certain 
dyes, etc. 

Pathology. — Congestion and infiltration of the various 
layers of the skin. 

Varieties. — E. erythematosus, E. papulosum, E. vesicu- 
losum, E. pustulosum, E. squamosum, and E. rubrum. 

Eczema ErythematOSUm. — This form consists in irregular 
patches marked by swelling, redness, and slight scaling, and 
accompanied by itching and burning. The most common seat 
is the face. 

Eczema Papillosum, — In this form there is a close aggrega- 
tion of minute acuminated papules accompanied by severe 
itching. It is frequently associated with the vesicular variety. 
The most common seat is the extremities. 

Eczema Vesiculosum. — This consists in an ill-defined red 
patch surmounted by minute vesicles, and accompanied by 
intense itching. The vesicles soon rupture and leave a raw, 
weeping surface which becomes more or less covered with 
crusts. In children, it is most common on the face ; in adults, 
on the extremities. 



ECZEMA. 447 

Eczema Pustulosum (Eczema Impetiginosum). — This consists 
in an aggregation of small pustules which break and lead to the 
formation of thick yellowish crusts. Itching is not marked. 
It is frequently associated with the vesicular variety. It is 
most commonly observed on the face and scalp of poorly- 
nourished children. 

Eczema Squamosum, — In this form there are irregular ill- 
defined red patches accompanied by considerable scaling. It 
differs from the erythematous form in the large amount of 
scaling. Its most common seat is the scalp. 

When there is a marked tendency to Assuring, as in chap- 
ping, this form is termed, eczema fissum ; and when there is a 
tendency to the formation of warty excrescences, it is termed 
eczema verrucosum. 

Eczema Rubrum (Eczema lladidans). — This is a secondary 
variety and is recognized by a raw, dark-red, moist surface, 
more or less covered with thick yellowish-red crusts. The 
itching may be severe. In children it is frequently noted on 
the face, and in old people on the extremities. 

Diagnosis. Scabies. — The history of contagion ; the loca- 
tion of the lesions — between the fingers, on the wrists, under 
the mammae, in the axillae ; and the presence of burrows will 
indicate scabies. 

Psoriasis. — The sharply-defined patches, the dry scaling, 
the absence of marked itching, the symmetrical distribution, 
and the predilection for extensor surfaces will indicate 
psoriasis. 

Acne Rosacea. — The presence of acne papules and pustules 
and of dilated bloodvessels, and the absence of itching will 
distinguish acne rosacea from erythematous eczema. 

Seborrhea. — The greasy scales and the absence of itching 
and of all inflammatory symptoms will indicate seborrhcea. 

Sycosis. — The limitation of the lesions to the hair-follicles 
of the face and the absence of itching will distinguish sycosis 
from eczema. 

Prognosis. — Generally favorable under persistent and judi- 
cious treatment. 

Treatment. General Treatment — The health must be 
improved. Tonics are frequently indicated. In strumous 



448 DISEASES OF THE SKIN AND ITS APPENDAGES. 

children cod-liver oil may be of extreme value. Disturbances 
of the gastro-intestinal tract are frequently present, and will 
require appropriate treatment. In the gouty and rheumatic 
the alkaline mineral waters, colchicum, and the salts of lithium 
are indicated. Constipation must always receive attention. 
Of the special internal remedies, arsenic is the most important ; 
it is, however, only indicated in the chronic cases in which 
bright redness, itching, and weeping are absent. 

External Treatment — In acute cases with marked inflam- 
matory symptoms, soothing applications should be employed. 
A saturated solution of boric acid may be dabbed on for five 
or ten minutes, and may be followed by zinc ointment spread 
on lint; when there is much itching carbolic acid is very 
useful : — 

fy. Acid, carbolic, 3j; 
G-lycerinae, 31J ; 
Aquae, q. s. ad f^viij. — M. 

Sig. — Apply locally. 

The following is also frequently used : — 
I£ Zinc oxid., ^ss ; 

Pulv. calaminae prsep., 9iv ; 

Glycerine, fgj ; 

Liq. calcis, f^vij. — M. 
Sig.— Shake and apply locally. 

In chronic cases crusts aud scales should be removed by 
soap and water or by : — 

fy Saponis virid., |ij ; 
Alcoholis, 3j. — M. 
Sig. — Apply thoroughly and remove with warm water. 

The best external applications are salicylic acid, tar, mer- 
cury, and resorcin : — 

j$L Acid, salicylic, gr. xx ; 
Unguent, petrolei, ^iv ; 
Amyli, 
Zinci oxid., aa ^ij.— M. 

(Stel wagon and Duhring.) 
Sig.— Apply twice daily. 

Or— 

I$l Hydrarg. ammoniati, £ss ; 
Liq. picis alkalin., £j ; 
Ung. aquse rosae, 3J.— M. 



LICHEN RUBER AND LICHEN PLANUS. 449 

Or— 

I£ 01. cadini, fgss ; 
Glycerinse, fgj ; 

JJng. diachyli, fgiiss. — M. (Tilbury Fox.) 
Sig. — Apply locally. 

LICHEN RUBER AND LICHEN PLANUS. 

Lichen Ruber. — This is an extremely rare disease, eharac- 
terized by the eruption of small, red, glazed, acuminated papules 
which show no tendency to coalesce, and which are associated 
with itching and failure of general health. The disease runs 
a chronic course, and may prove fatal through exhaustion. 

Lichen Planus. — This form is characterized by an eruption 
on the extremities of small, red, flat papules which tend to 
spread, and by coalescing form dull-red, irregular patches. 
The latter at first have a smooth and shiny appearance, but 
later are slightly scaly. There is more or less itching, but no 
impairment of the general health. As the old lesions disap- 
pear new ones take their place. 

Etiology. — These affections are most frequently observed 
in poorly-nourished, middle-aged males. 

Treatment. — The general health must be improved by 
good food and such tonics as iron, strychnia, and cod-liver oil. 
Arsenic is of considerable value. Locally, ointments of tar or 
mercury are useful. 

Lichen Scrofulosis. 

This is a chronic affection occurring chiefly in children of a 
strumous diathesis, and characterized by small, pale-red, or 
salmon-colored scaly papules. They tend to form in groups, 
and are most frequently observed on the trunk. Itching is 
absent. The disease runs a chronic course. 

Treatment. — Remedies like iron, quinine, and cod-liver 
oil are indicated. Hebra recommends the last remedy as a 
local application. 
29 



450 DISEASES OF THE SKIN AND ITS APPENDAGES, 

PRURIGO. 

Definition. — A chronic inflammatory disease, characterized 
by a general eruption of minute, discrete papules, accompanied 
by marked itching. 

Etiology. — It is most commonly observed in the poor and 
ill-fed of Europe. It develops in early childhood and persists 
through life. 

Symptoms. — An eruption of small, discrete, deeply-situated, 
pale-red papules appears on the body, especially on the back 
and extensor surfaces of the extremities. The skin is harsh, 
dry, and thickened, and covered with numerous scratch-marks 
induced bv the intense itching. 

Prognosis. — Unfavorable ; it usually persists through life. 

Treatment. — The general health must be improved by 
good food and the use of nutrient tonics like iron and cod- 
liver oil. Frequent bathing, followed by ointments of tar, 
sulphur, or naphthol, gives relief. 

DERMATITIS HERPETIFORMIS. 

(Herpes Gestationis, Duhring's Disease.) 

Definition. — A chronic inflammatory disease, characterized 
by multiform lesions which form in groups, and which are 
associated with intense itching. 

Etiology. — Women are more commonly affected than 
men. Pregnancy, lactation, and menstrual disorders seem 
to exert a predisposing influence. 

Symptoms. Erythematous Form. — This is characterized by 
the appearance in crops of erythematous patches which are 
associated with considerable itching. 

Papular Form. — Groups of papules appear in crops, and 
are frequently associated with erythema vesicles and scratch- 
marks. 

Vesicular Form. — Groups of irregular-shaped vesicles resem- 
bling herpes appear in crops and are often associated with 
erythema, pustules, and scratch-marks. 

Pustular Form. — This resembles the former, but the vesicles 
are replaced by pustules. 






DERMATITIS. 451 

Bullous Form. — Large irregular-shaped blebs appear in 
crops and tend to group. Vesicles and patches of erythema 
are also frequently present. 

Jlixed Form. — Vesicles, erythematous patches, pustules, 
papules, and blebs appear in association, come out in crops, 
and are attended with intense itching. 

In the pustular, bullous, and mixed forms there may be 
marked constitutional disturbances. 

Prognosis. — Guardedly favorable. The disease runs a 
chronic course. Eelapses are very common. 

Treatment. — Tonics are generally indicated. Lotions of 
boric or carbolic acid may be employed to allay itching, and 
may be followed by a dusting-powder. 

DERMATITIS. 

Definition. — Inflammation of the skin resulting from the 
action of some irritant. 

Dermatitis Traumatica — This term is applied to inflam- 
mation of the skin resulting from traumatism. 

Treatment. — The removal of the cause and the applica- 
tion of soothing remedies will usually suffice. 

Dermatitis Venenata. — The term is applied to inflamma- 
tion of the skin resulting from the application of vegetable, 
animal, or chemical irritants. Notable examples of this form 
of dermatitis are observed in susceptible people after exposure 
to the influence of poison ivy (Rhus Toxicodendron), poison 
oak (Rhus Venenata), or poison sumach (Rhus Diversiloba). 

Symptoms of Rhus-poisoning. — The affection resembles 
acute eczema, and may appear in a few hours or not until 
the lapse of several days after exposure to the plant. It is 
generally observed on the face or hands. The part becomes 
red and swollen, and soon minute papules and vesicles appear. 
It gives rise to considerable burning and itching. As a rule, 
it subsides in a few days, but in patients with sensitive skin 
it may linger for several weeks. 

Treatment. — The part should first be bathed with castile 
soap and tepid water, and then treated with some sedative 
lotion or ointment. Black wash may be dabbed on, and zinc 



452 DISEASES OF THE SKIN AND ITS APPENDAGES. 

ointment subsequently applied ; or a saturated solution of boric 
acid may be followed by zinc ointment. When there is marked 
itching a weak solution of carbolic acid (5j to Oj) is useful. 
The fluid extract of grindelia robusta has been highly recom- 
mended ; it may be applied in the strength of half an ounce 
to a pint of water. 

Dermatitis Calorica This term is applied to the inflamma- 
tion of the skin resulting from extreme heat or cold. Pernio, 
or chilblain, is characterized by redness, swelling, intense 
burning and itching, and results from a sudden change from 
a low temperature to a high temperature. Frost-bite is char- 
acterized by congelation ; the part is of a dull-white color and 
is anaesthetic ; subsequently inflammation or gangrene develops. 

Burns and scalds result from the application of heat, and 
are divided into degrees according to the depth to which the 
destructive process extends. 

Tkeatment. — In pernio, or chilblain, the part should first 
be rubbed with snow or bathed in ice-water until the circula- 
tion is re-established ; and then an application made of nitrate 
of silver (gr. v to the ounce of distilled water) or of tincture 
of iodine. 

In superficial burns or scalds one of the following remedies 
may be applied : Phenol sodique, carron oil (equal parts of lin- 
seed oil and lime-water), powdered bicarbonate of sodium, or: — 

J$l Acidi carbolic, gr. viij ; 

Vaselin., ^ij. — M. (Bellvue Hospital.) 
Sig. — Spread on lint aud apply where the skin is broken. 

Dermatitis Medicamentosa. — This term is applied to the 
various cutaneous eruptions which follow the internal use of 
certain drugs. 

Belladonna or Atropia. — These drugs produce a diffuse 
erythematous rash resembling that of scarlet fever, but it 
lacks the punctiform character of the latter. It usually ap- 
pears on the face, neck, and chest, and is associated with dry- 
ness of the throat, rapid pulse, and if the dose has been large, 
dilated pupils. 

Cubebs. — This drug sometimes produces an erythema asso- 
ciated with minute papules. 



ECTHYMA. 453 

Copaiba. — The rash may be macular, papular, or like that 
of urticaria. 

Bromide of Potassium. — The eruption resembles acne and 
consists of papules and pustules. 

Iodide of Potassium. — The eruption may be erythematous, 
papular, pustular, urticarial, or purpuric. The most common 
eruption resembles acne, but the lesions are bright-red in color 
and widely distributed over the surface of the body. 

Arsenic. — The eruption may be erythematous, papular, 
vesicular, or pustular. 

Antipyrin. — This drug not infrequently produces a wide- 
spread papular eruption. 

Quinine. — The rash is usually erythematous, though an 
urticarial eruption has been observed. 

Salicyl Compounds. — The eruption is usually erythematous 
or urticarial. 

Borax. — This drug occasionally produces an eruption resem- 
bling psoriasis. 

Chloral. — The eruption is usually erythematous or urticarial. 

Dermatitis Exfoliativa. 

This is a rare affection, characterized by diffuse redness of 
the skin, high fever and its associated phenomena, and des- 
quamation. It is interesting from its close resemblance to 
scarlet fever, from which it may be distinguished by the history 
and the absence of sore throat, and a " strawberry" tongue. 

ECTHYMA. 

Definition. — An inflammatory affection, characterized by 
the appearance of discrete, flat pustules, which vary in size 
from a pea to a five-cent piece, and which are surrounded by 
a distinct red areola. 

Etiology. — Male sex, middle life, bad hygiene, and de- 
bility are predisposing factors. 

Symptoms. — Flat, yellow pustules appear in crops. They 
are surrounded by a distinct red areola and soon dry up, form- 
ing reddish-brown crusts. Slight excoriation and pigmenta- 



454 DISEASES OF THE SKIN AND ITS APPENDAGES. 

tion sometimes remain after the separation of the crusts. 
Subjective phenomena are usually absent. 

Diagnosis. — The acute course, the absence of ulceration, 
and the absence of history and of associated symptoms of 
syphilis will separate it from the pustular syphilkle. 

Impetigo.— In this affection the lesions are not flat ; they are 
not distinctly inflammatory ; and the crusts are light yellow, 
not reddish-brown. Impetigo occurs most frequently in child- 
ren, who may be quite robust. 

Prognosis. — Favorable. 

Treatment. — Constitutional treatment is generally re- 
quired. Such tonics as iron, quinine, strychnia, and cod-liver 
oil are often indicated. 

Local Treatment. — The crusts should be removed and some 
stimulating ointment applied, as the following : — 

}$_ Hydrarg. ammoniat., gf. x ; 
Ung. zinci oxidi, ^j. — M. 

PEMPHIGUS. 

Definition. — A non-contagions inflammatory disease, char- 
acterized by the eruption of successive crops of bullae or blebs. 

Etiology. — Female sex, nervous prostration, heredity, and 
injury to the peripheral nerves are predisposing factors. 

Varieties. — Pemphigus vulgaris and pemphigus foliaceus. 

Pemphigus Vulgaris. — This form usually runs a chronic 
course and is characterized by successive crops of blebs, vary- 
ing in size from a small pea to a large walnut. They are 
thoroughly distended with fluid, which is at first clear but 
subsequently turbid. As a rule, they do not rupture, but dis- 
appear in the course of five or six days, their contents being 
gradually absorbed. After absorption a thin pellicle remains, 
which dries and is subsequently detached, leaving behind a 
slightly pigmented spot. ~No part of the body is exempt ; and 
as one set of blebs disappears, new ones rapidly develop, and 
so the disease continues for many years. 

In severe cases there may be considerable itching and burn- 
ing attending the eruption. 



IMPETIGO. 455 

Pemphigus Foliaceus. — This rare and grave form of pem- 
phigus is characterized by crops of blebs, which are flaccid and 
filled with a turbid fluid almost from the beginning. They 
soon rupture and form thick crusts, which separating leave 
behind red weeping surfaces. The crops follow each other in 
rapid succession, and at times the whole body may be covered 
with blebs and scabs. The disease may last several years, 
death ultimately resulting from exhaustion. 

Diagnosis. Bullous Syphiloderm. — The history, the asso- 
ciated symptoms of syphilis, the thick, yellow, stratified crusts, 
and the underlying ulceration will serve to separate this affec- 
tion from pemphigus. 

Impetigo Contagiosa. — The acute course, the contagious 
and auto-inoculable character of the affection, and the urnbili- 
cation of the blebs will separate impetigo contagiosa from 
pemphigus. 

Prognosis. — The prognosis should be guarded. Pemphi- 
gus vulgaris runs a long course and is often intractable. Pem- 
phigus foliaceus often proves fatal through exhaustion. 

Treatment. — The diet should be nutritious, but carefully 
adapted to the stomach. The patient should be placed under 
the best hygienic conditions. Tonics like iron, quinine, phos- 
phorus, cod-liver oil, and strychnia are usually indicated. In 
some cases arsenic may prove useful. 

Local Treatment. — The blebs may be punctured and 
subsequently dressed with zinc ointment. 

IMPETIGO. 

Definition. — An acute inflammatory disease, characterized 
by an eruption of discrete pustules varying in size from a pea 
to a cherry. 

Etiology. — The exciting cause is unknown. It is most 
commonly observed in children. 

Symptoms. — A pustular eruption appears generally on the 
face and extremities. The pustules are generally few in num- 
ber, and are discrete, tense, and surrounded by a slight areola. 
In a few days they dry up and form thin yellowish-brown 



456 DISEASES OF THE SKIN AND ITS APPENDAGES. 

crusts, which soon drop off and leave behind a normal surface. 
Subjective phenomena are absent. 

Diagnosis. Ecthyma. — This affection occurs most fre- 
quently in debilitated adults; the pustules are flat, sur- 
rounded by a distinct areola, and dry to brown crusts which 
separate and leave a pigmented excoriated surface. 

Impetigo Contagiosa. — As the name implies, this affection is 
contagious and is auto-inoculable ; its pustules are flat and um- 
bilicated, and dry up and form lamellated, thin, yellow crusts. 

Prognosis. — Favorable. It terminates spontaneously in a 
few days or a week. 

Treatment. — Open the pustules and apply some simple 
protective ointment, like that of oxide of zinc. 

IMPETIGO CONTAGIOSA. 

Definition. — An acute contagious inflammatory disease, 
characterized by flat, yellowish blebs which dry up and form 
thin, yellow, lamellated crusts. 

Etiology. — Its exciting cause is unknown. It is most 
frequently observed in debilitated children. 

Symptoms. — The eruption is most frequently observed on 
the face and extremities ; it generally appears in crops, and is 
at first vesicular. The vesicles grow, and are soon converted 
into flat, umbilicated pustules which vary in size from a pea 
to a large walnut. They have a slight red areola. Itching 
is slight or entirely absent. In some cases there is moderate 
fever with its associated phenomena. In a few days the blebs 
dry up and form thin, yellow, lamellated crusts which separat- 
ing leave a slightly excoriated surface. The disease is con- 
tagious, and the lesions are auto-inoculable. 

Diagnosis. Eczema. — In this disease the pustules are 
similar, more confluent, excite intense itching, and are asso- 
ciated with inflammation and infiltration of the surrounding 
skin. 

Simple Impetigo. — This affection is not contagious or auto- 
inoculable ; the pustules are tense, not flat or umbilicated ; 
and the subsequent crusts are yellowish-brown and are not 
followed by excoriation. 



MILIARIA. 457 

Prognosis. — Favorable. It terminates spontaneously in a 
few days or weeks. 

Treatment. — A slight stimulating ointment like the fol- 
lowing is sometimes useful : — 

^ Hydrarg. ammon., gr. v ; 
Adipis, Jj. — M. 
Sig. — Apply to the surface after removal of the crusts. 

MILIARIA. 

(Prickly Heat.) 

Definition. — An acute inflammatory disease of the sweat- 
glands, characterized by a discrete eruption of minute papules 
and vesicles. 

Etiology. — Childhood and high temperature are the prin- 
cipal predisposing causes. 

Symptoms. — The eruption generally appears on the trunk, 
and consists of minute closely-aggregated red papules or clear 
vesicles. The lesions are discrete, and excite some burning 
and itching. It is generally associated with free perspiration. 

Diagnosis. — Eczema papulosum differs from miliaria in 
that the papules are larger, appear more gradually, disappear 
more slowly, and excite intense itching. 

Eczema vesiculosum differs from miliaria in that the vesicles 
are large, disappear more slowly, show a tendency to break, 
and are associated with marked itching. 

Sudamen differs from miliaria in that it lacks all inflamma- 
tory characteristics. 

Prognosis. — Favorable. Obstinate cases may persist for 
several weeks. 

Treatment. — The general health may require attention. 
The diet should be light, and easily assimilable. Constipation 
should be relieved by saline laxatives. Locally, a simple 
dusting-powder is generally all that is required. 

^ Pulv. amyli, gvj ; 
Zinc, oxidi, ^iss ; 

Pulv. camph., £ss.— M. (Hakdaway.) 
Sig. — Dusting-powder. 



458 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Or— 

1$l Zinc, carbonat. prsecip., giv : 
Zinc, oxidi, 31J ; 
Glycerinse, f ^ij ; 

Aq. rosse, f^viij.— M. (Tilbury Fox.) 
Sig. — Apply locally. 

ALBINISM. 

Definition.— A congenital deficiency of pigment. 

Etiology. — Beyond heredity, no cause is known. Partial 
albinism is more common in the negro. 

Symptoms. — In complete albinism the skin is white ; the 
hair is thin, soft, and very light in color ; the pupils appear 
red, the eyes are very sensitive to light, and the iris and 
choroid are deficient in pigment. 

VITILIGO. 

(Leucoderma.) 

Definition. — An acquired cutaneous affection, character- 
ized by milk-white patches which are surrounded by areas of 
increased pigmentation. 

Etiology. — The disease seems to be more common in the 
tropics and in the colored race. The condition probably 
results from disturbed innervation. 

Symptoms. — Milk-white spots appear on the body and 
grow very slowly ; their borders usually reveal an increase of 
the normal pigment. Apart from the absence of pigment the 
skin is normal. 

Diagnosis. Morphoea. — The initial hyperemia and the 
subsequent atrophy of the skin will serve to distinguish 
morphoea from vitiligo. 

Ancesthetic Leprosy. — The subjective symptoms, the atrophy 
of the tissues, and the anaesthesia will separate leprosy from 
vitiligo. 

Prognosis. — Unfavorable ; the disease usually persists 
through life. 

Treatment. — Tonics and local stimulants may be tried. 
Among the latter, electricity, blisters, and irritating ointments 
have been recommended. 






CANITIES ATROPHY OF THE HAIR. 459 

CANITIES. 

Definition. — Grayness of the hair. 

Etiology. — Local grayness may be congenital, or result 
from some disturbance of innervation, as in neuralgia of the 
supraorbital nerve. As a general condition it is usually an 
expression of senility, although it occasionally develops very 
early m life. Profound emotional disturbances sometimes 
induce an abrupt development of canities. 

Prognosis. — The condition is permanent, and treatment is 
of no avail. v 

ATROPHIA CUTIS. 

Etiology. — Atrophy of the skin occurs under several con- 
ditions. A local atrophy may result from inflammation or 
injury of a nerve-trunk ; in these cases, the wrinkles are absent, 
the skin is thin, smooth, and shiny, and there is often intense 
burning in the part (" glossy skin"). Atrophy is also ob- 
served in leprosy, morphcea, and scleroderma. 

Universal atrophy of the skin results from senility, and 
very rarely as an idiopathic condition. Sometimes the atrophy 
occurs in lines or spots (strice et maculce atrophica^) as an 
idiopathic condition, or as the result of stretching the skin, as 
in the linece albiccudes following pregnancy. 

ATROPHY OF THE HAIR. 

Etiology. — Atrophy of the hair may result from local 
diseases which interfere with the nutrition of the scalp, such 
as seborrhoea, eczema, ringworm, etc. ; or it very rarely arises 
as an idiopathic condition without obvious cause. 

Prognosis. — When the cause can be ascertained and re- 
moved, the prognosis is favorable. 

Treatment. — Local diseases will require appropriate treat- 
ment. The general health should be improved. Stimulating 
applications of mercury, sulphur, or carbolic acid are sometimes 
useful. 



460 DISEASES OF THE SKIN AND ITS APPENDAGES. 



ATROPHY OF THE NAIL. 

Etiology. — Occasionally the condition is congenital, but 
more frequently it is acquired, and results from injury or dis- 
ease of the nerve-trunk ; from some general disease, like one 
of the fevers, syphilis, or cancer ; or from some disease of the 
skin, as psoriasis or ringworm. 

Symptoms. — The nails lose their lustre, cease to grow, and 
become opaque and brittle. 

Prognosis and Treatment. — Both will depend on the 
exciting cause. 

ALOPECIA. 

(Baldness.) 

Etiology.— (1) Baldness may be congenital ; in these cases 
it is usually partial. (2) It may be an expression of senility ; 
in which case it generally begins on the crown or brow, and is 
associated with more or less atrophy of the scalp. (3) It may 
occur early in life, as an idiopathic affection arising without 
obvious cause. (4) It may result from general diseases, like 
syphilis and the fevers. (5) In early life it is often due to 
some local disease, especially seborrhoea. 

Prognosis. — In congenital, senile, and idiopathic alopecia 
the prognosis is unfavorable. In the alopecia of general dis- 
eases the prognosis is usually favorable. In alopecia result- 
ing from seborrhoea much can be accomplished by persistent 
and judicious treatment. 

Treatment. — The general health should be improved. 
Frequent washing the head with warm water and castile soap 
is to be recommended. One of the following local stimulants 
may be prescribed : Cantharides, quinine, alcohol, capsicum, 
sulphur, or carbolic acid. 

fy Quininse sulph., ^ss ; 
Tinct. cantharidis, f^j ; 
Spt. ammon. aromat., f §j ; 
Ol. ricini, f^iss ; 
Spt. myrcire, f^vss ; 
Ol. rosmarini, gtt.v.— M. (Gerhard.) 



Or— 



Or— 



ALOPECIA AREATA. 4(U 



I£ Tinct. cantharidis, f^j ; 
Acid, carbolici, gj ; 
Ol. ricini, £iss ; 
Spt. myrcise, 
Spt. lavandulse, aaf^ij. — M. 



$. Tinct. cantharidis, gij ; 
Quininse sulph., gr. x ; 
Glycerinse, f^ss ; 
Ol. rosmarini, gtt. v ; 
Spt. myrcise, q. s. adf^v. — M. 



ALOPECIA AREATA. 

(Alopecia Circumscripta.) 

Definition. — Baldness appearing in circumscribed patches 
without any obvious lesion of the skin. 

Etiology. — The cause is unknown. Some regard it as of 
parasitic origin, while others look upon it as a neurosis. It 
is generally observed in early adult life. 

Symptoms. — The disease is characterized by the sudden or 
gradual appearance of circumscribed round patches of bald- 
ness. At first there is no change in the appearance of the 
skin, but later it may become pale and atrophied. Although 
the scalp is the most frequent seat, it occasionally involves 
other hairy parts, as the eyebrows, beard, etc. 

Diagnosis. Ringworm. — Ringworm is exceedingly rare in 
adults, and is characterized by elevated scaly patches through 
which project dry, brittle, broken hairs. If there should be 
any doubt in the diagnosis, the microscope may be employed 
to detect the tricophyton. 

Prognosis. — In the majority of cases the hair returns 
under prolonged and persistent treatment. The older the 
patient the less favorable the prognosis. 

Treatment. — General tonics like iron, arsenic, quinine, and 
strychnia are usually indicated. The local treatment should 
be stimulating and consist in the application of blisters, elec- 



462 DISEASES OF THE SKIN AND ITS APPENDAGES. 

tricity, friction, rubefacient liniments, or ointments containing 
chrysarobin, tar, sulphur, or ammoniated mercury. 

I£ Tinct. cantharidis, 

Tinct. capsici, aa f^iss ; 
Olei ricini, fjij ; 
Alcoholis, f^vj ; 
Spts. rosmarini, f^ij. — M. 

(Duhring and Stel wagon. ) 



Or— 
Or— 



fy. Acid, chrysophauic, ^iss ; 
Adipis, 3ij. — M. 

J$l Sulphur, loti, £iv ; 
01. cadini, 31J ; 
Adipis, jfj.— M. 

SYCOSIS. 

(Simple Sycosis, Folliculitis Barbae.) 

Definition. — A non-contagious inflammatory disease of 
the hair-follicles. 

Etiology. — The affection probably results from local irri- 
tation. 

Symptoms. — The disease usually manifests itself on the 
bearded region of the face, and is characterized by an aggre- 
gation of papules and pustules, each of which is pierced by a 
hair. When the lesions are discrete the intervening skin is 
often quite healthy ; but when they are close together it is 
often infiltrated and hypersemic. During the papular stage 
the hairs are not loose, but firmly attached ; during the pus- 
tular stage, however, they can be readily extracted. The 
pustules show no tendency to rupture, but dry to yellowish- 
brown crusts. Acute cases are associated with more or less 
burning and itching. If the disease persists, it may lead to 
extreme destruction of the hair-follicles and, as a consequence, 
to permanent alopecia. 

Diagnosis. Eczema. — The lesions in eczema are not dis- 
crete, are not perforated by hairs, and are not confined to the 
hairy parts. 

Tinea Sycosis, or Barber's Itch. — The affection begins as a 



POMPHOLYX. 463 

reel scaly patch, and is followed by the development of large, 
deeply-seated tubercles. The hairs soon become dry, brittle, 
and broken off, and can be easily extracted. In doubtful 
cases the microscope may be employed for the detection of the 
tricophyton. 

Prognosis. — The disease is curable under prolonged and 
judicious treatment. Relapses are very prone to occur. 

Treatment. — In acute cases soothing applications are in- 
dicated ; thus the parts may be dabbed with black wash or 
a saturated solution of boric acid, and subsequently spread 
with oxide of zinc ointment. In chronic cases the crusts 
should be removed, and the hairs cut close or preferably, 
shaved. It is advisable to puncture the pustules and to ex- 
tract the hairs, so as to preserve the follicles. When the parts 
are not irritable stimulating applications are useful, and one 
of the following may be selected : — 

I£ Sulphur, prsecip., £ij ; 
Ung. aqure rosae, ^j. — M. 
Sig. — Apply twice daily. 

Or— 

$. Ung. diachylon, 

Ung. zinc, oxidi, aa ^iss ; 

Ung. hydrarg. amnion., 3iij ; 

Bismuth, subnitratis, ^iss. — M. (Kobinson.) 
Sig. — Apply twice daily. 

Or— 

fy Ichthyol., 3j ; 

Ung. diachylon, gj ; 
Sig. — Apply twice daily. 

POMPHOLYX. 

(Dysidrosis.) 

Pompholyx is a very rare disease, usually observed in those 
who perspire freely, and characterized by an eruption of 
deeply-seated vesicles which resemble sago-grains imbedded 
in the skin. The vesicles most commonly appear on the hands, 
especially between the fingers, and gradually increase in size 



464 DISEASES OF THE SKIN AND ITS APPENDAGES. 

until they reach the dimensions of blebs. They show no 
tendency to rupture, but dry up, and are followed by exten- 
sive desquamation of the cuticle. The eruption often excites 
considerable pain and tenderness. The disease usually dis- 
appears in the course of a few weeks, but is prone to recur. 

Treatment. — General tonics like iron, strychnia, and 
arsenic are often indicated. Locally, sedative lotions or oint- 
ments should be employed. 

LENTIGO. 

(Freckle.) 

Definition. — A deposition of pigment in the form of 
small, irregular-shaped brownish spots. 

Etiology. — Blondes are more subject to the affection than 
brunettes. Exposure to the sun's rays often serves as an 
exciting cause. 

Symptoms. — Exposed parts — the face, shoulder's, arms, and 
hands — are mostly affected. The patches vary in color from 
yellow to dark brown, and range in size from a pin-head to a 
pea. 

Prognosis. — Freckles can be removed, but they always 
return. 

Treatment. — One of the best remedies is the bichloride of 
mercury in solution or ointment. 

J$l Hydrarg. ehlor. corros., gr. iv ; 
Alcohol, et aquae, aa ad f§iv. — M. 
Sig. — Apply twice daily. 

CHLOASMA. 

Definition. — An abnormal deposition of pigment in the 
form of large brown or liver-colored patches. 

Etiology. — It may result from the application of external 
irritants ; from general diseases like malaria and Addison's 
disease; or from affections of the uterus, as pregnancy, 
tumors, etc. 

Symptoms. — The affection consists in the appearance — 
especially on the face — of large, round, or irregular-shaped 






KERATOSIS PILARIS. 465 

brownish or blackish patches. Apart from the discoloration 
the skin is normal. 

Diagnosis. — In Leucoderma the periphery of the patches 
is pigmented, but the central milk-white appearance is not 
seen in chloasma. 

Prognosis. — When the cause can be removed the prog- 
nosis is favorable. 

Treatment. — When possible the cause should be removed. 
The best local remedies are bichloride of mercury and sul- 
phur. 

]£ Zinci oxidi, gr. iij ; 

Hydrarg. ammoniat., gr. iss ; 
Ol. theobrom., 
01. ricini, aa giiss ; 

Essent. rosse, gtt. x.— M. (Monin.) 
Sig. — Apply to the face night and morning. 

KERATOSIS PILARIS. 

(Lichen Pilaris.) 

Definition. — Small, papular elevations resulting from 
hypertrophy of the epidermis surrounding the outlets of the 
hair-follicles. 

Etiology.— It generally results from infrequent bathing. 

Symptoms. — The skin, particularly on the extensor sur- 
faces of the arms and legs, is the seat of numerous pin-head 
elevations, which have a dirty-gray color and are pierced by 
hairs. It may excite some itching. Generally there are no 
evidences of inflammation, but sometimes a few red papules 
or even pustules result from irritation. 

Diagnosis. — In Cutis Anserina, or goose-flesh, the lesions 
are transient and have the color of normal skin. 

Prognosis. — Favorable. 

Treatment. — In most cases nothing will be required be- 
yond frequent bathing with soap, followed by friction of the 
skin. In obstinate cases some simple ointment may be ap- 
plied after bathing. 

30 



466 DISEASES OF THE SKIN AND ITS APPENDAGES. 

MOLLUSCUM EPXTHELIAXE. 

(Molluscum Contagiosum, Molluscum Sebaceum.) 

Definition. — A cutaneous affection, characterized by the 
appearance of discrete wax-like elevations ranging in size from 
a pin-head to a pea, and varying in color from white to rose- 
pink. 

Etiology. — The disease is generally observed in children, 
and frequently affects several members of the same household, 
school, or asylum. It is probably contagious. 

Symptoms — Small white or pale-pink, wax-like elevations 
appear, especially on the face. They are always discrete and 
rarely abundant. The centre of the elevation is depressed 
and reveals a dark spot which corresponds to the aperture of 
the follicle. At first the lesions are quite firm, but as they 
grow old they become soft. When firmly squeezed they 
exude a soft, cheesy material. After remaining for several 
weeks they break down or undergo slow absorption. 

Diagnosis. — The color, the wax-like appearance, the um- 
bilication, and the central aperture are the diagnostic features. 

Prognosis. — Favorable, although the disease may run a 
protracted course of months or years. 

Treatment. — General tonics like iron, strychnia, and 
arsenic are often indicated. The lesions should be incised, 
the contents expressed, and their bases touched with nitrate of 
silver ; ointments of mercury and sulphur have also been rec- 
ommended. 

CALLOSITAS. 

(Callus, Keratoma, Tylosis.) 

Definition. — A thickened, horny condition of the skin 
resulting from hypertrophy of the corneous layer of the epi- 
dermis. 

Etiology. — Constant irritation from friction or pressure is 
the chief cause ; hence it is frequently seen on the feet from 
the rubbing of shoes, and on the hands from the friction of 
tools. 



CLAVUS. 467- 

Symptoms. — The condition is characterized by the gradual 
appearance of hard, thickened, grayish masses, which gradu- 
ally merge into healthy skin. The soles and palms are the 
parts most frequently affected. When slight it causes little 
inconvenience, but occasionally it becomes fissured and pain- 
ful. 

Prognosis. — It yields rapidly to treatment when the cause 
is removed. 

Treatment. — When excessive the parts should be soaked 
and the thickened epidermis pared off. One of the best reme- 
dies for softening the horny overgrowth is salicylic acid j it 
may be applied in the form of a plaster or in collodion. 

fy Acid, salicylic, 3j ; 
Collodii, fgj.— M.' 
Sig. — Apply night and morning. 

CLAVUS. 

(Corn.) 

Definition. — Clavus is a circumscribed thickening of the 
epidermis usually appearing on the feet. 

Etiology. — Corns generally result from the friction of ill- 
fitting shoes. 

Symptoms. — Small, circumscribed, horny elevations appear 
upon the feet and often excite severe pain. When bathed in 
perspiration they become more or less macerated, and in this 
condition constitute the so-called soft corn. 

Treatment. — A radical cure requires the use of well- 
fitting shoes. The corns may be removed by soaking, paring, 
and the application of some mild caustic like salicylic acid. 

T$l Acid, salicylic. , gr. xxx ; 
Tinct. iodin., TTlx ; 
Ext. cannabis ind. , gr. x ; 
Collodii, f^ss.— M. 
Sig. — Apply night and morning for several days, and then soak 
in hot water. 



468 DISEASES OF THE SKIN AND ITS APPENDAGES. 

CORNU CUTANEUM. 

(Cutaneous Horn.) 

Definition.— A circumscribed, projecting outgrowth re- 
sulting from hypertrophy of the epidermis. 

Symptoms. — Horns generally appear on the face, scalp, or 
penis, and are usually observed in the old. They consist of 
dry, rough, horny, more or less conical projections, which vary 
in length from a few lines to several inches. 

Prognosis. — Favorable. 

Treatment. — The horn should be excised and the base 
subsequently cauterized. 

VERRUCA. 

(Wart.) 

Definition. — A wart is a circumscribed elevation result- 
ing from hypertrophy of the papillae and epidermis. 

Etiology. — The cause is obscure. A bacterial origin has 
been suggested. They are most frequently observed in 
children. 

Symptoms. — Verruca Vulgaris, or common wart, is gener- 
ally observed on the hands of children. It consists of a firm, 
circumscribed elevation, varying in size from a millet-seed to 
a pea. 

Verruca plana, or flat wart, is a circumscribed, flat, pig- 
mented elevation usually observed on the backs of old people. 

Verruca Filiformis. — This is a thread-like overgrowth, and 
is generally observed on the soft parts, like the face and neck. 

Verruca Digitaia. — This form is made up of numerous 
branches, and is generally observed on the scalp. 

Verucca Acuminata, or Venereal Wart. — This appears in 
groups about the genitalia. It is soft, red in color, and highly 
vascular. It may be dry or moist according to its location ; 
the latter condition often gives rise to a peculiarly offensive 
odor. 

Treatment. — Ordinary warts may be removed by ex- 
cision, caustics, or electrolysis. 






ICHTHYOSIS. 469 

Venereal warts should be bathed in some antiseptic solution 
and subsequently dusted with calomel, iodoform, or boric acid. 



N^EVUS PIGMENTOSUM 

(Mole.) 

Definition. — A circumscribed deposit of pigment, usually 
associated with hypertrophy of cutaneous structures. 

Etiology. — Moles are usually congenital. 

Symptoms. — The neck, face, and trunk are favorite locali- 
ties. The nsevi vary in number from one to several hundred ; 
in size, from a millet-seed to a filbert ; and in color, from yel- 
low to black. When the surface is smooth, the growth is 
termed ncevus spilus ; when the surface is covered with hair, it 
is termed ncevus pilosus ; when the surface is warty, it is 
termed ncevus verrucosus ; and when there is much overgrowth 
of connective tissue, it is termed ncevus lipomatocles. 

Treatment. — They may be removed by excision, the ap- 
lication of caustics, or by electrolysis. 

ICHTHYOSIS. 

(Fish-skin Disease.) 

Definition. — A chronic affection characterized by dryness, 
thickening of the epidermis, and scaliness. 

Etiology. — The affection is often hereditary and is usually 
detected in early childhood. 

Symptoms. — The skin is dry and harsh ; the surface is 
covered with adherent polygonal scales ; and the papilla are 
more or less hypertrophied. The term Ichthyosis hystrix is 
applied to the condition when there is excessive hypertrophy 
of the papillae. The extensor surfaces of the extremities are 
the parts most involved. 

Diagnosis. — The absence of all inflammatory symptoms 
will separate ichthyosis from squamous eczema and psoriasis. 

Prognosis. — The disease is incurable ; but the patient can 
be rendered comfortable by appropriate treatment. 



470 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Treatment. — The scales may be removed by alkaline 
baths or by applications of green soap. The skin may be 
rendered pliable by rubbing in some simple ointment. 

$. Sulphuris, gr. xxv-1 ; 

Ung. simp., gj.— M. (Unna.) 
Sig. — Rub in at night. 

ONYCHAUXIS. 

Onychauxis, or hypertrophy of the nail, may be congenital, 
or may result from certain skin affections, such as eczema, 
ringworm, or syphilis ; from diseases of the nerves, as neuritis ; 
or from traumatism. 

HYPERTRICHOSIS. 

(Hirsuties.) 

Hypertrichosis, or hypertrophy of the hair, may be local or 
general. The term is applied not only to an excessive over- 
growth of hair, but to a growth of hair iu unusual localities, as 
on the faces of young women. 

Treatment. — The hair may be removed temporarily by 
shaving, epilation, or depilatories. Permanent relief can only 
be accomplished by electrolysis. 

SCLERODERMA. 

(Sclerema, Scleriasis.) 

Definition. — A pigmented, rigid, indurated condition of 
the skin, occurring in circumscribed patches or involving the 
entire body. 

Etiology. — The cause is unknown. 

Symptoms. — The affection may be diffuse or involve cir- 
cumscribed patches. It may appear quite suddenly, or develop 
very gradually in the course of months or years. The skin 
assumes a .yellowish -brown color, becomes rigid, indurated, 
and hide-bound ; the surface is unnaturally dry and smooth. 
When the condition is advanced the joints become more or 
less immobile. 






MORPHCE A — ELEPH ANTIASIS. 471 

Prognosis. — Guarded. It often recovers spontaneously 
after having persisted for a long time. In other cases the pro- 
cess may spread until the patient becomes almost helpless. 

Treatment. — Tonics like iron, arsenic, and cod-liver oil 
are often indicated. Locally, massage, friction, electricity, 
and inunctions are recommended. 

MORPHCEA. 

(Addison's Keloid.) 

Definition. — A cutaneous affection, characterized by cir- 
cumscribed, rounded, ivory-like patches, which have hypersemic 
or pigmented borders. 

Etiology. — The cause is unknown. It is generally re- 
garded as a circumscribed form of leucoderma. 

Symptoms. — The lesions usually appear upon the trunk 
and consist of sharply-circumscribed patches, which are at 
first slightly hypersemic. The surface is smooth and resistant 
to the touch. As the patch grows old its centre becomes pale 
and ivory-like, while the periphery remains hypersemic or be- 
comes pigmented. 

Prognosis. — Guarded. 

Treatment. — The same as scleroderma. 



ELEPHANTIASIS. 

(Elephantiasis Arabum, Elephantiasis Pachydermia, Barbadoes 

Leg.) 

Definition. — Hypertrophy of the skin and subcutaneous 
tissues, usually associated with lymphangitis, oedema, and pig- 
mentation. 

Etiology. — While elephantiasis may occur in any part of 
the world, it is far more common in the tropics. It is most 
frequently observed in the male sex, and rarely develops 
before adult life. It results from obstruction of the lym- 
phatics, and the most common cause of such obstruction is the 
presence of a parasite — filaria sanguinis hominis. 



472 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Pathology. — Examination of the affected tissues reveals 
hypertrophy of the connective tissue, oedema, and inflamma- 
tion and dilatation of the lymphatic vessels. 

Symptoms. — It usually begins with recurring attacks of 
erysipelatoid inflammation. The part is red, swollen, and 
painful ; the lymphatics may be traced as branching red lines 
beneath the skin ; and with these local phenomena there is 
more or less fever. After each attack the part is left a little 
enlarged, until finally it presents the following characteristic 
appearance : it is enormously swollen ; the skin is thickened, 
roughened, and pigmented ; and the papilla? are unusually 
prominent. The regions generally affected are the legs and 
genitals. In elephantiasis of the scrotum {lymph-scrotum) the 
hypertrophied mass may weigh as much as fifty or even a 
hundred pounds. 

Prognosis. — In the early stage the disease may be arrested, 
but when fully established it is incurable. 

Treatment. — The acute inflammatory attacks should be 
treated by rest and the application of sedative lotions, like 
lead-water and laudanum. Subsequently mercurial inunc- 
tions may be employed, and the part firmly bandaged with 
the view of promoting absorption. Amputation may be suc- 
cessfully employed in lymph-scrotum. In elephantiasis of 
the limbs ligation of the main artery has given somewhat 
encouraging success. More recently galvanism has given very 
good results. 

DERMATOLYSIS. 

(Pachydermatocele, Cutis Pendula.) 

Definition. — A circumscribed hypertrophy of the skin 
and subcutaneous tissues resulting in a softened and pendulous 
condition of the integument. 

Symptoms. — The part affected is thickened and pigmented ; 
it is soft and fat-like to the touch ; and when the condition is 
marked, the skin hangs in folds. The regions generally 
affected are the shoulders, arms, back, and buttocks. 

Treatment. — The redundant tissue may be removed by 
excision or electrolysis. 



KELOID — FIBROMA. 473 

KELOID. 

(Cheloid, Kelis.) 

Definition. — A new growth resulting from hypertrophy of 
the connective tissue of the corium. 

Etiology. — It generally results from local injury, though 
it is claimed that it may arise spontaneously. Certain fami- 
lies and individuals are especially predisposed. It is more 
frequent in the colored race. 

Symptoms. — It begins as a pale-red nodule, which slowly 
increases in size and sends out claw-like processes. From its 
resemblance to a crab it has been termed keloid. It is firm, 
elastic, slightly elevated, sharply defined, and ranges in size 
from a small bean to a growth as large as the hand. It 
sometimes excites pain and itching, but generally subjective 
phenomena are absent. The regions most frequently involved 
are the chest and back. 

Diagnosis. — Keloid may be distinguished from a hyper- 
trophied scar by the fact that the latter does not extend beyond 
the limits of the injury. 

Prognosis. — The growth is usually permanent, and after 
removal invariably returns. 

Treatment. — It may be removed temporarily by excision, 
electrolysis, or caustic pastes. 

FIBROMA. 

(Molluscum Fibrosum.) 

Definition. — A circumscribed overgrowth derived from 
the subcutaneous connective tissue. 

Etiology — Early life and heredity are predisposing factors. 

Symptoms — The tumors are circumscribed ; painless ; soft 
or firm ; often multiple ; range in size from a pea to a hen's 
egg ; and do not impair the general health. The overlying 
skin may be normal in appearance or slightly hypersemic. 

Prognosis. — They are permanent and treatment is rarely 
indicated. 



4:74 DISEASES OF THE SKIN AND ITS APPENDAGES. 

ANGIOMA. 

(Naevus Vasculosus.) 

Definition. — A new growth, composed of cavernous tissue, 
or a congeries of small bloodvessels. 

Angioma Cavernosum. — This form is congenital, is com- 
posed of cavernous tissue, and appears as a circumscribed, 
elevated, dark-red tumor, which ranges in size from a pea to 
one as large as the hand. It is often lobulated and pulsating. 

Angioma Simplex {Capillary Ncevus,Port-icine Mark). — This 
form is also congenital, and is composed of a congeries of ca- 
pillaries. It is non-elevated, bright-red or purple-red in 
color, and may cover an area of several inches. It- is gener- 
ally found on the face, and constitutes what is popularly 
termed a mother's mark. 

Telangiectasis, — This form is acquired, and is composed of 
dilated or newly-developed capillaries. It appears as a bright- 
red dot from which branch dilated capillaries. It is fre- 
quently associated with acne rosacse ; it is also common in 
those of a gouty diathesis and in those much exposed to the 
weather. 

Treatment. — Cavernous angiomata may be removed by 
ligation, excision, or electrolysis. Simple angiomata and telan- 
giectasis are best treated by electrolysis. 

XAOTHOMA. 

(Vitiligoidea, Xanthelasma . ) 

Definition. — A circumscribed connective-tissue new- 
growth appearing as flat patches or tubercles of a yellowish 
color. 

Etiology. — Middle life and female sex are general pre- 
disposing factors. Hepatic disorders, especially obstructive 
jaundice, seem to exert a decided predisposing influence. 

Symptoms. — There are two forms : Xanthoma planum, 
which generally appears about the eyelids and consists of 
smooth, circumscribed, slightly elevated, buff-colored patches ; 
and Xanthoma tuberosum, which may appear on the neck, 



LUPUS ERYTHEMATOSUS. 475 

shoulders, trunk, or extremities, and consists of small, elastic, 
and yellowish-colored nodules. 

Treatment. — These growths may be removed by excision, 
electrolysis, or caustics. 

LUPUS ERYTHEMATOSUS. 

(Seborrhcea Congestiva.) 

Definition — Lupus erythematosus is a new-growth result- 
ing from a cellular infiltration of the skin, and characterized 
by circumscribed, red patches which are more or less covered 
with yellowish-gray adherent scales. 

Etiology. — Middle life and female sex are predisposing 
factors. It frequently arises from disorders of the sebaceous 
glands, as seborrhcea or acne. 

Pathology. — By many it is regarded as a chronic derma- 
titis which originates in the sebaceous glands. 

Symptoms. — The disease usually manifests itself on the 
face, iu the region of the nose, and appears as small, red, 
slightly elevated papules, which are more or less scaly. An 
erythematous patch is gradually formed by the coalescence of 
these papules. The periphery of the patch is elevated and 
sharply defined, while the centre is depressed and atrophied. 
The ducts of the sebaceous glands are dilated and often filled 
with sebum. The disease spreads very slowly, shows no ten- 
dency to ulceration, and rarely excites any subjective symptoms. 

Diagnosis. — The location, the sharply-defined red patch 
with an elevated margin and depressed centre, the slight seali- 
ness, the dilated sebaceous ducts, the chronic course, and the 
absence of ulceration are the diagnostic features. 

Lupus Vulgaris. — This affection begins earlier in life, is 
characterized by tubercles and ulceration, and lacks involve- 
ment of the sebaceous glands. 

Prognosis. — Favorable under prolonged and judicious 
treatment. 

Treatment. — General tonics like iron, arsenic, phos- 
phorus, and cod-liver oil are often indicated. 

Local Treatment. — In many cases mild applications 
accomplish the most good. Much benefit is often derived 



476 DISEASES OF THE SKIN AND ITS APPENDAGES. 

from washing the part thoroughly with green-soap and alcohol 
for a few days and then applying the following lotion : — 

J$l Zinc, sulpahtis, 

Potassi sulpbidi, aa ^ij ; 
Aquse, fjiij ; 

Alcoholis, i^j.— M. (Duhring.) 
Sig. — Shake well, dab the parts for fifteen minutes twice daily, 
and allow to dry on. 

In sluggish cases stimulating applications are useful, and 
one of the following may be selected : — 

I$l Acid, salicyl., £ss ; 
Acid, lactic, £ss ; 
Resorcin., gr. xlv ; 
Zinc, oxid., gij ; 
Yaselin. pur., gxvij.— M. (Broca.) 

Or— 

I$l Acidi pyrogallici, 3j ; 

Cerati simplicus, gix. — M. (Kaposi.) 
Sig. — Apply locally. 

In obstinate cases, scarification, curetting, or burning with 
the galvano-cautery may be employed with advantage. 



LUPUS VULGARIS. 

(Lupus Exedens.) 

Definition. — A local manifestation of tuberculosis, char- 
acterized by soft red tubercles, which usually terminate in ul- 
ceration and scarring. 

Etiology. — Early life and female sex are general pre- 
disposing factors. It is comparatively rare in this country, 
but very common in Austria and Germany. The exciting 
cause is the tubercle bacillus. 

Symptoms. — Lupus vulgaris most frequently manifests it- 
self on the face, especially near the nose. It begins as minute, 
deeply-seated, reddish-brown papules, which grow very slowly 
until they reach the dimensions of tubercles. They are smooth, 
quite soft, and seldom painful. At this stage they may either 
undergo slow absorption or, which is more frequent- break down 
and leave chronic ulcers. The ulcers are shallow, and their 



LUPUS VULGARIS. 477 

edges are soft and red. There is very little discharge. They 
spread slowly, and may involve all the soft parts, but the bone 
is never invaded. While one part of the ulcer is spreading, 
other parts are being filled with shrivelled cicatricial tissue 
which in turn is often the seat of new tuberculous nodules. 

Diagnosis. Epithelioma. — Epithelioma is a disease of ad- 
vanced life ; it begins as a firm, wax-like nodule ; the resulting 
ulcer starts from a single point ; its borders are distinctly ele- 
vated and hard ; it secretes a blood-streaked fluid ; and it is 
often painful. 

Syphilis — The age, history, associated evidences of syphilis, 
the rapid course, the deep uleers, the abundant offensive dis- 
charge, and later the involvement of the bones, are the diag- 
nostic features. 

Prognosis. — Very guarded. Its removal is often followed 
by relapse. 

Treatment. — General tonics like iron, arsenic, phos- 
phorus, and cod-liver oil are usually indicated. 

Local Treatment. — The growth may be removed by cauter- 
ization, curetting, excision, or electrolysis. One of the fol- 
lowing caustic applications may be employed : — 

$. Acid, arseniosi, 9j ; 

Hydrarg. sulphuret. rub., 3j ; 
Ung. simplicis, 3j.— M. (Hebra.) 
Sig. — Spread thick on cloth, and apply to the patch for two or 
three days, until lupus nodules and points are blackish or destroyed. 

Or— 

I£ Acid, lactic, puri, f^.—M. (Wichmann.) 
Sig. — Soak a pledget of absorbent cotton and apply to the ulcer. 
Cover with oil-silk and bandage. Protect normal tissue with grease. 

Or— 

fy Acid, salycilic, ^ij ; 
Adipis benzoat., %]. — M. 
Sig. — Apply locally. 

Often the best results are obtained by curetting and subse- 
quently applying caustics. 

Koch's tuberculin has lately been employed extensively in 
the treatment of lupus, but it has not given such good results 
as were expected. After its use most cases improve, many 



478 DISEASES OF THE SKIN AND ITS APPENDAGES. 

relapse, a few recover. It seems best adapted to rapidly- 
spreading forms of lupus. 

SYPHILIS CUTA1STEA. 

The secondary symptoms appear between the first and fourth 
month following the chancre, and are characterized by a sym- 
metrical arrangement, a coppery color, polymorphism (many 
forms at the same time), and an absence of itching. They are 
usually associated with certain general symptoms, such as sore 
throat, pain in the bones, loss of hair, enlargement of the 
lymphatic glands, and failure of health. 

The tertiary symptoms appear in from six months to several 
years after the primary sore. They are as a rule localized, 
are tubercular, gummatous, or ulcerative in form, and tend to 
group. 

Macular Syphiloderm, — This is a secondary manifestation, 
and consists in a general eruption of dark-red macules, vary- 
ing in size from a millet-seed to a ten-cent piece. 

Diagnosis. Measles. — The absence of fever, of catarrh, of 
a crescentic arrangement, together with the history, will pre- 
vent an error in diagnosis. 

Papular Syphiloderm. — This may be an early or late mani- 
festation, and is characterized by a general eruption of large 
or small, dull-red papules. A few pustules are also frequently 
present. It pursues a chronic course, finally disappearing by 
desquamation, and leaving behind slight pigmentation. 

Diagnosis. — The history, distribution, dark color, and the 
presence of pustules will separate it from keratosis pilaris, 
papular eczema, and lichen ruber. 

Tuberculous Syphiloderm. — A late manifestation, charac- 
terized by a localized eruption of dark-red shiny papules 
varying in size from a pea to a large bean. By some these 
tubercles are regarded as gummatous in character. They pur- 
sue a chronic course and finally disappear by absorption or 
ulceration. The ulcers thus formed, when single, are round, 
punched out, and frequently covered with crusts ; when they 
coalesce, they form a serpiginous sore which pours forth a thick 
yellowish discharge. 



SYPHILIS CUTANEA. 479 

Diagnosis. Lupus Vulgaris. — This occurs in earlier life; 
it pursues an extremely chronic course ; the ulcer is superficial ; 
the tubercles are soft, and frequently redevelop in the scar tis- 
sue; the secretion is scant; and the bone is never involved. 

Epithelioma. — In this affection the progress is slower ; there 
is only one point of ulceration ; the secretion is scanty ; and 
the border is markedly infiltrated. 

Bullous Syphiloderm.— This is a late manifestation, and is 
characterized by an eruption of well-filled blebs varying in size 
from acoffee-bean toa walnut. The contents of the blebs are puri- 
form. They subsequently form dark, conical, stratified crusts 
under which are ulcers pouring forth a thick, purulent fluid. 

Diagnosis. Pemphigus. — The history, the concomitant 
symptoms of syphilis, and thick, greenish crusts will serve to 
distinguish syphilis from pemphigus. 

Gummatous Syphiloderm.— This appears as a firm, circum- 
scribed nodule which gradually turns red and softens. It 
may disappear by absorption, or break down and leave a deep 
punched-out ulcer. 

Moist Papules {Mucous Patches). — These consist in soft flat 
papules covered with an offensive, grayish secretion. Heat 
and moisture favor their development, so that their favorite 
seats are around the arms, the genitalia, the mouth, and in 
women under the mammae. 

Papulosquamous Syphiloderm. — This may be an early or 
late manifestation, and is characterized by a general erup- 
tion of small papules which are more or less scaly, so as to 
resemble psoriasis. 

Diagnosis. — The history, the slight scaling, the dirty-gray 
color of the scales, the dark-red color of the lesions, the espe- 
cial tendency to involve the palms and soles will serve to dis- 
tinguish syphilis from psoriasis. 

Squamous Eczema. — In this affection the distribution, the 
infiltration of the skin, and the marked itching will lead to 
a correct diagnosis. 

Annular Syphiloderm. — In this form the lesions consist of 
circles or semi-circles of small dark-red papules. 

Pustular Syphiloderm. — This form usually appears within 
the first year, and is characterized by a general eruption of small 



480 DISEASES OF THE SK1X AND ITS APPENDAGES. 

or large, acuminated or flat pustules which finally dry up 
and form yellowish-brown crusts. Large lesions leave super- 
ficial ulcers. The term rupia is applied to large, conical, 
stratified crusts which rest loosely on the ulcerating basis. 

Diagnosis. Variola. — Absence of syphilitic history, the 
shot-like feel, the umbilication, the itching, the high fever, and 
the acute course will separate variola from syphilis. 

Acne. — This is usually limited to the face and shoulders ; 
there is no history of syphilis or concomitant symptoms of 
that affection. 

Treatment. — The internal treatment consists in the ad- 
ministration of iodide of potassium, mercurials, and tonics. 

^ Hydrarg. iodic!., gr. j ; 
Potass, iodid., 31V ; 
Syr. sarsaparilla? co., 
Aquae, aa fgij.— M. (R. W. Taylor.) 
Sig. — Teaspoonful three times a day after meals. 

Or— 

J$l Hydrarg. protiodidi, gr. v-x : 

Ext. opii, gr. v.— M. (Hardaway. 
Ft. in pil. No. xx. 
Sig. — One morning and evening. 

Local Treatment. — Papular eruptions may be washed 
with mercurial lotions ; mucous patches may be dusted with 
calomel ; ulcers may be dressed with iodoform. 

LEPROSY. 

(Lepra, Elephantiasis Graecorum.) 

Definition. — A chronic contagious disease, excited by the 
bacillus of leprosy, and characterized by tubercular formations, 
ulcerations, atrophy, disturbances of sensation, and an in- 
crease or decrease of pigment. 

Etiology. — The disease is contagious, but direct inocula- 
tion is essential to its transmission. It seems to be more 
common in hot climates. The exciting cause is the bacillus 
leprae, which closely resembles the tubercle bacillus. 

Varieties. — There are two varieties : Tubercular leprosy 
and anaesthetic leprosy ; but the two forms are often associated 
in the same patient. 



LEPROSY. 481 

Symptoms. — Certain prodromes may precede the outbreak 
of the disease, such as malaise, headache, chilliness, depression 
of spirits, and numbness in the parts to be affected. 

Tuberculur Leprosy. — In this form spots of erythema ap- 
pear on the body ; they soon become pigmented and hyper- 
aesthetic, and develop into tubercles varying in size from a pea 
to a walnut. The face, extremities, and genitals are the parts 
most commonly affected, but occasionally the mucous mem- 
branes, especially of the nose and throat, are invaded. Ulti- 
mately the tubercles may break down and leave superficial 
indolent ulcers. In some cases a bullous eruption appears 
from time to time. The hair, eyebrows, and eyelashes fall out, 
the eyes become inflamed, the features distorted, and the voice 
husky. The disease may last many years, death finally result- 
ing from exhaustion or some intercurrent disease. 

Ancesthetic Leprosy. — In this form the peripheral nerves 
are invaded by the bacillus leprae. The outbreak may be 
preceded' by numbness, itching, or lancinating pains. These 
symptoms are followed by the appearance of discolored spots, 
which are at first associated with hyperesthesia, but later more 
or less anaesthesia develops. The skin and its appendages 
atrophy, the bones undergo necrosis, and the phalanges drop 
off one by one. In some cases (lepra alba) the skin is not 
only anaesthetic, but distinctly white. Finally, when the nerves 
are more or less destroyed paralysis results. The duration is 
many years. 

Prognosis. — Unfavorable. A cure is practically impos- 
sible, though the progress of the disease may be stayed by 
appropriate treatment. 

Treatment. — Sufferers should be isolated. Tonics are 
usually indicated. Chaulmoogra oil and gurgun oil, inter- 
nally and externally, have been highly recommended. Exter- 
nally, chrysarobin, iehthyol, or resorcin may be applied to the 
affected parts. 

^ Chrysarobin, gr. X-3J ; 
iEtheris et alcoholis ad q. s. 
Collodii, f^j.-M. (G. H. Fox.) 
Rub the chrysarobin with a little alcohol and ether, and add the 
collodion. 

Sig.— Paint the affected patch with a camel's-hair brush. 
31 



482 DISEASES OF THE SKIN AND ITS AFPEKDAGES. 

EPITHELIOMA. 

(Skin Cancer.) 

Etiology. — Late life, heredity, and local irritation are the 
predisposing factors. 

Varieties. — Superficial, deep-seated, and papillomatous. 

Superficial Epithelioma {Rodent Ulcer). — This form usually 
begins as a firm, circumscribed, reddish-yellow, wax-like 
papule. After the lapse of several months or years the papule 
becomes scaly, and the removal of the scales is followed by a 
slight excoriation, which in turn becomes covered with a slight, 
reddish-brown crust. The latter tends to adhere, and its re- 
peated removal is followed by a raw surface, which is gradu- 
ally converted into an ulcer. The ulcer has a prominent in- 
durated margin ; its outline is irregular ; its base is uneven 
and glazed ; and it exudes a sanious viscid excretion. It is 
not painful ; it does not lead to enlargement of the neighboring 
lymphatic glands ; nor does it cause impairment of the gen- 
eral health. It spreads very slowly, and sometimes becomes 
stationary or actually heals. More frequently the ulceration 
continues until it involves all the tissues of the part, even the 
bones. The ulcer generally appears on the face, and in its 
advance it may destroy the nose, eyes, or a large portion of the 
cranial bones. 

Deep-seated Epithelioma. — This variety may begin as a 
deep-seated, red, shiny tubercle, or it may develop from the 
superficial form. The ulcer which is ultimately formed is 
deep ; its base is granular ; its edges are everted, indurated, 
and of a reddish-purple color ; it secretes a blood-stained 
yellow fluid ; it is the seat of lancinating pain ; it causes en- 
largement of the neighboring glands ; and it sooner or later 
induces the cancerous cachexia. Death may result from ex- 
haustion, or more rarely, from hemorrhage caused by ulcer- 
ation of a large bloodvessel. 

Papillomatous Epithelioma. — This may begin as a warty 
excrescence, or may develop from one of the preceding varie- 
ties. It is characterized by an ulcerated surface from which 
springs an aggregation of large, highly-vascular papillae. Be- 






AINHUM — DERMATALGIA. 48o 

tween the papillae there are often deep-seated fissures from 
which exudes au offensive viscid discharge. The general 
health is impaired and the neighboring glands are enlarged. 

Diagnosis. Lupus Vulgaris. — Lupus begins in the young ; 
the original papule is soft ; there is often more than one centre 
of ulceration ; the margins of the ulcer are not hard and 
everted ; the progress is extremely slow ; the discharge from 
the ulcer is very scant, and the bones are never involved. 

Syphilis. — The history, the associated evidences of syphilis, 
the rapid progress of the ulceration, the abundant discharge, 
the absence of pain, and the effect of treatment will suggest 
the diagnosis. 

Prognosis. — Guarded. A thorough removal in the begin- 
ning of the disease is often followed by a permanent cure. 
When the process is advanced the growth usually returns. 

Treatment. — Epitheliomatous growths may be removed 
by the use of caustics, the cautery, the curette, or by ex- 
cision. The last is preferable when the growth is small and 
circumscribed. 

AINHUM. 

Ainhum is a rare affection, occurring chiefly in the colored 
race, and characterized by the appearance of a groove or fur- 
row at the base of one or more of the toes. The groove deep- 
ens, the affected member becomes swollen, and finally drops 
off at the point of strangulation. 

DERMATALGIA. 

Dermatalgia, or neuralgia of the skin, is a rare affection, 
and is characterized by paroxysms of sharp, lancinating pain 
in the skin, which arise without any change in the local ap- 
pearance. It is most frequently observed in women of a 
neuropathic tendency, and may arise from any of the causes 
which induce neuralgia elsewhere. 

Treatment. — The cause must be sought for and, if pos- 
sible, removed. Tonics like iron, arsenic, quinine, and phos- 
phorus are often indicated. Locally, massage and electricity 
may prove useful. 



484 DISEASES OF THE SKIN AND ITS APPENDAGES. 



PRURITUS. 

Definition. — Pruritus is a functional affection, character- 
ized by itching which is unassociated with any objective phe- 
nomena. 

Etiology — Pruritus may arise without obvious cause, as 
the Pruritus senilis observed in the old, and the pruritus 
hiemalis which develops on the approach of cold weather and 
disappears when the weather becomes warm. 

Symptomatic Pruritus. — Pruritus may be a symptom of 
many conditions, notably diabetes, gout, lithsemia, hysteria, 
neurasthenia, and Bright 's disease. 

Symptoms. — There is only one symptom and that is itching ; 
but as a result of scratching, the part may become hypersemic, 
thickened, or the seat of eczema. 

Diagnosis. — Pruritus must be distinguished from the itch- 
ing induced by pediculosis, or some local disease, like eczema. 

Prognosis. — This will depend on the cause. When the 
primary disease is curable the prognosis for permanent relief 
is favorable. In other cases temporary relief only is to be ex- 
pected. 

Treatment. — Search should be made for the exciting 
cause, which should be removed, if possible. In all cases the 
urine must be examined for sugar, since diabetes is one of the 
most frequent causes of pruritus. Among the internal reme- 
dies recommended for pruritus may be mentioned mix vomica, 
belladonna, and pilocarpin. The best local remedies are car- 
bolic acid, vinegar, thymol, chloral-camphor, boric acid, 
hydrocyanic acid, hot water, and menthol. 

I£ Acid, hydrocyan. dil., f^ij ; 
Sodii borat., 3J ; 
Aq. rosae, f^viij. — M. (Fox.) 
Sig. — Use locally. 

ty Menthol, 3iss ; 

Alcoholis, f|iv.— M. 
Sig. — Use locally. 

$. Acid, carbolic, fgj-fsjij ; 

Aquse et alcohol., aa q. s. ad Oj. — M. 
Sig. — Apply locally as often as necessary. 



TINEA TRICOPHYTINA. 485 

TINEA TRICOPHYTINA. 

(Ringworm.) 

Definition. — A contagious disease excited by a vegetable 
parasite — the tricophyton. 

Varieties. — On the scalp it is termed Tinea tonsurans ; on 
the body, Tinea circinata ; on the bearded region, Tinea 
sycosis. 

Tinea Tonsurans. 

This form is observed almost exclusively on the scalp of 
children. It is characterized by one or more rounded, scaly, 
elevated, grayish-colored patches through which project dry, 
brittle, lustreless, broken-off hairs. 

Diagnosis. Seborrhoea. — The patches are not circum- 
scribed ; the scales are greasy ; the hair is not involved ; and 
the microscope reveals no parasite. 

Eczema. — The patches are not circumscribed ; the hair is 
not involved ; there is more inflammation ; there is marked 
itching ; and the microscope reveals no parasite. 

Alopecia Areata. — Baldness is complete ; there are no scales; 
and the base is smooth and shiny. 

Prognosis. — Favorable. 

Treatment. — Tonics are often indicated. The parts 
should be thoroughly washed with soap and water, and the 
affected hairs removed. The following parasiticides may be 
employed in ointment or lotion ; mercury, sulphur, chrysarobin, 
or sulphurous acid. 

]£ Acid, sulphurosi, f^j ; 
Aquae, f |iv.— M. 
Sig. — Apply several four or five times daily. 

Or— 

I£ Acid, carbolic, cryst., 

Ung. hydrarg. nit., 

Ung. sulphuris, aa sjss. — M. 
Sig.— Apply thrice daily. (Van Harlingen.) 



486 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Tinea Circinata. 

(Ringworm of the Body.) 

This appears as one or more rounded, red, slightly-elevated 
scaly patches, which on close examination reveal minute 
vesicles or papules. As the disease advances new patches 
spring from the periphery while the central portion clears up. 
There is often considerable itching. 

Diagnosis. Psoriasis. — The marked scaling ; the absence 
of itching ; the tendency to involve the extensor surfaces, es- 
pecially the knees and elbows ; and the absence of the tri- 
cophyton will separate psoriasis from ringworm. 

Eezema. — The patches are ill defined ; there is more itching; 
there is more infiltration of the skin ; and there is no trico- 
phyton. 

Prognosis. — Favorable. 

Treatment. — Tonics are frequently indicated ; mercury, 
sulphur, sulphurous acid, and hyposulphite of sodium are 
among the best parasiticides. 

I£ Sodii hyposulphit.,3ij ; 

Aquae, f^ij.—M. (Duhrixg.) 
Sig. — Apply locally. 

Or— 

]£ Hydrarg. ammoniat.. gr. xxx ; 
Adipis, ^j. — M. 
Sig.— Apply localry. 

Tinea Sycosis. 

(Barber's Itch, Sycosis Parasitica.) 

This begins as a red scaly patch involving the bearded 
region. Soon purplish tubercles and pustules form around 
the opening of the hair-follicles, and the hairs become lustre- 
less, brittle, and loose. There is often considerable itching. 

Diagnosis. Simple Sycosis. — In this the inflammation is 
superficial ; the hairs are not involved ; and the tricophyton 
is absent. 



TINEA VERSICOLOR. 487 

Eczema. — The tubercles, the involvement of the hairs, and 
the presence of the tricophyton will separate it from eczema. 

Prognosis. — Favorable ; unless treated actively, however, 
there may be a permanent loss of hair. 

Treatment. — The affected hairs should be removed, and 
one of the following parasiticides employed in lotion or oint- 
ment : Mercury, sulphur, or hyposulphite of sodium. 

J$l Sodii hyposulphit., 3iij ; 
Aquse, f§iij. — M. 
Sig. — Apply locally. 
Or— 

]£ Sulphur, sublimat., 31J ; 
Vaselini, ^ij. 
Sig. — Apply locally. 

TIKEA VERSICOLOR. 

(Pityriasis Versicolor.) 

Definition. — A chronic affection excited by a vegetable 
parasite, the microsporon furfur, and characterized by salmon- 
colored scaly patches which usually appear about the chest. 

Etiology. — It is a disease of adult life, and is more fre- 
quently observed in the debilitated and uncleanly. 

Symptoms. — It appears usually on the front of the chest as 
small round spots of a pale-yellow or fawn color, which slowly 
enlarge, fuse, and form slightly-elevated scaly patches. Sub- 
jective symptoms are generally absent. 

Diagnosis. — Chloasma somewhat resembles tinea versi- 
color ; but the former is not often observed on the trunk, is 
not scaly, and is not associated with a parasite. 

Prognosis. — Favorable. 

Treatment. — The parts should be frequently washed with 
soap and water, after which one of the following parasiticides 
may be applied : Corrosive sublimate (gr. ij to an ounce of 
water), sulphurous acid, or hyposulphite of sodium : — 

I£ Sodii hyposulphitis, ^v ; 
Glycerine, f^iij ; 
Aqua?, q. s. ad fgv.— M. 
Sig. — Apply locally. 



488 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Or— 

]£ Hydrarg. chlor. corros., 9j ; 

Alcoholis, fjiv ; 

Saponis viridis, f^ij ; 

01. lavandulae, fgj.— M. (Van Harlingen.) 
Sig. — To be rubbed in well night and morning. 

TINEA FAVOSA. 

(Favus.) 

Definition. — A contagious affection of the scalp excited 
by the achorion Schbnleinii, and characterized by yellowish, 
cup-shaped crusts. 

Etiology. — It is observed especially in poor, ill-nourished 
children. 

Symptoms. — The disease is characterized by one or more 
rounded, yellow, cup-shaped crusts, through which project 
dry, brittle, lustreless hairs. The underlying tissue is more 
or less atrophied and scarred. It is associated with some itch- 
ing and a peculiar musty odor. 

Diagnosis. — The yellow, cup-shaped crusts, the odor, and 
the atrophy of the skin will separate it from ringworm. 

Peognosis. — Favorable When not treated early it may 
be followed by permanent baldness. 

Treatment .-^The crusts should be removed by oil, or 
soap and water. The affected hairs should also be removed. 
The following parasiticides are efficient : Mercury, sulphur, 
chrysarobin, and hyposulphite of sodium. 

SCABIES. 

(Itch.) 

Definition. — Scabies is a contagious disease excited by an 
animal parasite — the Acarus Scabiei — and manifested by pap- 
ules, vesicles, pustules, burrows, and intense itching. 

Etiology. — The disease is always acquired through inti- 
mate intercourse with patients already affected. 

Symptoms. — The disease manifests itself by intense itching, 
which is associated with an eruption of small papules, vesicles, 



PEDICULOSIS. 489 

and pustules. Among these lesions may be found cuniculi, or 
burrows ; these are discolored, dotted, slightly elevated lines 
ranging from a line to half an inch in length, and produced 
by the penetration of the female acarus and the deposition 
of her eggs along the passage. The parts most commonly 
affected are the hands between the fingers, the wrists, the 
axillae, the genitalia, beneath the mamma?, and the inner 
aspects of the thighs. The face and scalp are never involved. 

Diagnosis. — The recognition of scabies rests on the history, 
the itching, the presence of burrows, the multiformity of the 
lesions, and their peculiar distribution. 

Prognosis. — Favorable. 

Treatment. — The following remedies are efficient : Sul- 
phur, styrax, and naphthol. 

}$_ Sulphur, sublimat., ^j ; 
Balsam. Peruvian., ^ss ; 
Adipis, 5j.— M. (Duhring.) 
Si©-. — Eub in thoroughly twice daily. 



Gl- 



or- 



ia Naphthol., gr. lxxx ; 
Saponis viridis, ^ss ; 
Cretse alb. pulv., gr. 1 ; 
Adipis, 3j.— M. (Kaposi.) 



]£ Storacis, f|j ; 

Spt. vin. rect., fgij. — M. 
Et adde— 

01. oliv£e, fsj. (McCall Anderson.) 
Sig. — Rub the parts thoroughly ; repeat in twenty-four hours. 

PEDICULOSIS. 

(Phtheiriasis.) 

Pediculosis Capitis,— This form results from the pediculus 

capitis, or head-louse, a gray insect from one to two milli- 
metres in length. The condition is recognized by itching of 
the scalp and the discovery of the lice or their white ova, or 
nits. Eczematous lesions resulting from scratching are often 
observed. 



490 DISEASES OF THE SKIN AND ITS APPENDAGES. 

Pediculosis Corporis.— This form results from the pediculus 
corporis, pediculus vestimenti, or body-louse, a somewhat 
larger insect than the head-louse. The condition is recog- 
nized by intense itching on the covered parts of the body, 
scratch-marks, petechia? caused by the bite of the insect, and 
the discovery of the lice on the garments. 

Pediculosis Pubis — This form results from the pediculus 
pubis, or crab-louse, a minute, gray, translucent insect. It is 
found on parts covered with short hair, as the pubes, axillae, 
eyebrows, etc. 

Treatment. — In pediculosis capitis the head may be thor- 
oughly washed with coal-oil, dilute carbolic acid (3j to Oj), or 
tincture of cocculus indicus. 

In pediculosis corporis the parts should be thoroughly washed 
and the clothes subjected to a high temperature. The body may 
be bathed in a weak solution of corrosive sublimate. 

In pediculosis pubis an ointment of mercury is very efficient. 



INDEX 



ABDOMEN, distention of, 23 
Abscess, cerebral, 350 
bepatic, 80 
perinepbritic, 106 
retropharyngeal, 30 
Acetone, test for, 93 
Acetonuria, causes of, 93 
Acbolia, 73 
Acidity, gastric, 20 

degree of, 21 
test for, 21 
Acids, fatty, in sputum, 159 
Acne, 440 
Acromegalia, 405 
Addison's disease. 115 
^Igophony, 167 
Agraphia, 388 
Ague, 250 
A in hum, 483 

Alse nasi, movement of, 153 
Albinism, 458 
Albumin, tests for, 92 
Alopecia, 460 

areata, 461 
Amoeba coli, 52 
Anaemia, 111 

cerebral, 340 

essential, 112 

idiopathic, 112 

lymphatic, 115 

pernicious, 112 

primary, 112, 113 

symptomatic, 111 

varieties of, 111 
Anaesthesia, causes of, 320 
Analgesia, causes of, 321 
Anchylostomum duodenale, 64 
Aneurism, aortic, 148 
Angina pectoris, 147 
Angioma, cutaneous, 474 



Anidrosis, 430 

Animal parasites, 62 

Ankle-clonus, 320 

Anorexia, 19 

Anosmia, 154 

Anuria, 85 

Aortic aneurism, 148 

Aortic valves, diseases of, 135, 136 

Apex-beat, 119 

changes in the force of, 120 

displacement of, 120 
Aphasia, 387 
Aphemia, 387 
Aphonia, causes of, 154 
Apoplexy, cerebral, 341 

pancreatic, 69 

pulmonary, 199 
Appendicitis, 58 
Appetite, disturbances of, 19 
Argyll-Robertson pupil, 328 
Argyria, 415 

Arteries, obstruction of cerebral. 345 
Arthritis deformans, 300 

rheumatoid, 300 
Arthropathies, 323 
Ascaris lumbricoides, 63 
Ascites, 67 
Asthma, 191 
Ataxia, locomotor, 357 
Athetosis, 316 
Atrophy, facial, 405 

idiopathic muscular, 369 

myopathic, 369 

muscular, causes of, 323 

of liver, acute yellow. 84 

progressive muscular, 365 
Auscultation, immediate, 166 

mediate, 166 

of chest, 165 

of heart, 123 

(491) 



492 



INDEX. 



BACILLUS, tubercle, 159 
detection of, 160 
Bell's palsy, 383 
Beriberi, 381 
Bile-ducts, catarrh of, 73 
Bile in the urine, 94 

tests for, 94 
Blebs, causes of, 422 
Blood, diseases of, 109 
Bothriocephalus latus, 62 
Bouliinia, 19 
Brachycardia, 126 
Brain, abscess of, 350 

anaemia of, 340 

congestion of, 339 

tumors of, 347 
Breath, fetor of, 18 
Breathing, amphoric, 166 

asthmatic, 167 

bronchial, 166 

cavernous, 166 

Cheyne-Stokes, 156 

cogged-wheel, 167 

exaggerated, 166 

in emphysema, 167 

jerky, 167 

normal, 166 

puerile, 166 

tidal-wave, 156 

weak, 167 
Bright's disease, acute, 97 

chronic, 99, 100 
Bromidrosis, 431 

Bronchial tubes, dilatation of, 189 
Bronchiectasis, 189 
Bronchitis, 182 

acute catarrhal, 182 

capillary, 187 

chronic, 184 

fibrinous, 188 
Bronchophony, 167 
Bronchorrhagia, 198 
Bruit, aneurismal, 125 
Bullae, causes of, 422 



CACHEXIA, malarial, 254 
\J Calculus, renal, 103 
Calculi, biliary, 74 
Callositas, 466 
Cancer, gastric, 42 



Cancer — 

hepatic, 81 

pancreatic, 69 
Cancrum oris, 25 
Canities, 459 
Caput Medusae, 416 
Carbunculus, 444 

Cardiac dulness, diminished area of, 
123 
increased area of, 123 
Catalepsy, 327 
Catarrh, autumnal, 194 

biliary, 73 

bronchial, 182, 184 

gastric, acute, 33 
chronic, 37 

intestinal, 48 

nasal, 171 

pharyngeal, 30 

suffocative, 187 
Causalgia, 322 
Cephalalgia, 375 
Cerebro-spinal fever, 247 
Charcot-Leyden crystals in sputum, 

159 
Chest, auscultation of, 164 

dulness of, on percussion, 165 

emphysematous, 161 

expansion of, 163 

funnel, 162 

inspection of, 161 

mensuration of, 169 

palpation of, 161 

percussion of, 164 

phthisinoid, 161 

rachitic, 161 
Chest-walls, oedema of, 163 
Cheyne-Stokes respiration, 156 
Chicken-pox, 266 
Chloasma, 464 
Chlorides in the urine, 89 
Chlorosis, 113 
Cholaemia, 73 
Cholelithiasis, 74 
Cholesteraemia, 73 
Cholera, Asiatic, 283 

infantum, 56 

morbus, 55 
Cholerine, 284 
Chorea, Huntingdon's, 316 

minor, 396 



INDEX. 



493 



170 



21 



Chorea — 

insaniens, 397 
Choreiform movements, causes of, 

315 
Cirrhosis, hepatic, 77 

pancreatic, 69 
Clavus, 467 
Cold in the head 
Cold, rose, 194 
Colic, biliary, 75 

definition of, 

intestinal, 47 

mucous, 49 

renal, 104 
Coma, causes of, 325 
Comedo, 433 

Compensation in cardiac disease, 135 
Conception, imperative, 329 
Congestion, cerebral, 339 

hepatic, 76 

pulmonary, 200 

renal, 95 
Consciousness, disturbances of, 325 
Consumption, pulmonary, 216 
Contraction, paradoxical, 320 
Convulsions, 313 

epileptiform, 313 

hysteroidal, 314 

local, 315 

salaam, 315 

tetanic, 314 

varieties of, 313 
Cornu cutaneum, 468 
Corpuscles, red, diminution of, 109 

white, increase of, 109 
Coryza, 170 
Cough, causes of, 156 

dry, 156 

laryngeal, 157 

moist, 157 

winter, 184 
Cow-pox, 262 
Cramp, artisans', 400 

writers', 400 
Cretinism, 351 
Crisis, definition of, 231 

diseases terminating by, 235 
Croup, false, 176 

membranous, 177 

pseudo-membranous, 177 

spasmodic, 176 



Croup — 

true, 176 
Crusts, cutaneous, causes of, 422 
Cyanosis, causes of, 129 

congenital, 129 



DECUBITUS, 325 
Defecation, painful, causes of, 22 
Degeneration, reactions of, 323 
Delusion, varieties of, 329 
Delirium, definition of, 329 

causes of, 329 

tremens, 408 
Dermatalgia, 483 
Dermatitis, 451 

exfoliativa, 453 

herpetiformis, 450 
Dermatolysis, 472 
Dengue, 328 
Diabetes insipidus, 308 

mellitus, 304 
Diacetic acid, tests for, 93 
Diaceturia, causes of, 93 
Diarrhoea, 47 

varieties of, 48 
Diathesis, uric-acid, 303 
Diphtheria, 274 
Dipsomania, 408 
Disease, Addison's, 115 

Basedow's, 402 

bleeder's, 116 

caisson, 368 

Duchenne's, 357 

Friedreich's, 362 

Graves's, 402 

Hodgkin's, 115 

Landry's, 367 

Marie's, 405 

Meniere's, 390 

Parkinson's, 398 

Raynaud's, 403 

Thomsen's, 401 
Diuresis (see Polyuria), 85 
Dizziness, 389 
Dropsy, causes of, 129 
Dysentery, 52 

amoebic, 52, 53 

catarrhal, 52 

chronic, 53 

diphtheritic, 52, 53 



494 



INDEX. 



Dysentery — 

malignant, 52, 53 
Dyspepsia, 34 

atonic, 35 

catarrhal, 37 

nervous, 35 



ECHINOCOCCUS of the liver, 83 
Ecstasy, 327 
Ecthyma, 453 
Eczema, 446 
Effusion, abdominal (see Ascites), 67 

pericardial, 131 

pleural, 224 
Elephantiasis, 471 
Embolism, cerebral, 345 
Emphysema, cutaneous, causes of, 
416 

pulmonary, 195 

varieties of, 195 
Empyema (see Purulent Pleurisy), 225 
Endocarditis, 133 

acute, 134 

chronic, 135 

malignant, 141 

sclerotic, 133 

ulcerative, 141 

vegetative, 133 
Enteritis, acute, 48 

catarrhal, 48 

chronic, 48 

membranous, 49 
Entero-colitis, 51 
Entrorrhagia, causes of, 22 
Epilepsy, 385 
Epistaxis, causes of, 154 
Epithelioma, cutaneous, 482 
Erysipelas, 268 
Erythema, 436 

Eruptions, time of appearance of, 233 
Exhaustion, heat, 407 
Expectoration, varieties of, 157 
Eyeball, tremor of, 328 
Eyes, conjugate deviation of, 328 



1ACE, atrophy of, 405 
palsy of, 383 
spasm of, 372 



Fastigium, definition of, 231 
Favus, 488 
Febricula, 236 
Fecal discharges, 22 
Festination, 317 
Fever, 230 

break- bone, 288 

catarrhal, 280 

causes of, 232 

cerebro- spinal, 247 

degrees of, 231 

detection of, 230 

effects of, on tissue, 232 

ephemeral, 236 

enteric, 237 

famine, 245 

hay, 194 

intermittent, 250 

jungle, 252 

lung, 202 

malarial, 250 

pulse-temperature, ratio in, 232 

relapsing, 245 

remittent, 252 

rheumatic, 290 

scarlet, 256 

simple continued, 236 

spirillum, 245 

spotted, 247 

stages of, 230 

symptoms of, 232 

terminations of, 231 

thermic, 406 

treatment of, 232 

types of, 331 

typhoid, 237 

typhus, 243 

yellow, 270 
Fevers, continued, 231 

intermittent, 231 

remittent, 231 
Fibre, elastic, in sputum, 158 
Fibromata, cutaneous, 473 
Filaria sanguinous hominis, 64 
Floating kidney, 107 
Fremitus, tactile, 163 

vocal, 163 
Friction-sound, pericardial, 125 

pleural, 224 
Furunculus, 443 



INDEX. 



495 



GAIT, ataxic, 317 
spastic, 317 

steppage, 317 
(rail-ducts, inflammation of, 73 
Gall-stones, 74 

Gangrene, symmetrical, 325, 403 
Gastralgia, 39 
Gastric cancer, 42 

ulcer, 40 

catarrh, 33, 37 
Gastritis, acute, 33 

chronic, 37 
Gastrodynia, 39 
Glottis, oedema of, 181 

spasm of, 179 
Glucose, tests for, 90 
Glycosuria, causes of, 90 
Goitre, exophthalmic, 402 
Gout, 297 

latent, 303 

rheumatic, 300 
Graphospasm, 400 
Green sickness, 113 



H^IMATEMESIS, causes of, 45 
Haematoidin in the sputum, 159 
Hematoma of the dura mater, 334 
Haematuria, causes of, 93 
Haemoglobin, diminution of, 110 
Hsemoglobinuria, causes of, 94 
Hsemopericardium, 113 
Haemophilia, 116 
Haemoptysis, causes of, 198 
Hair, atrophy of, 459 

hypertrophy of, 470 

trophic affections of, 325 
Halluciuation, 329 
Hay-fever, 194 
Headache, 375 
Heart, auscultation of, 123 

dilatation of, 143 

fatty degeneration of, 145, 146 
infiltration of, 145 

fibroid, 142 

hypertrophy of, 143 

inspection of, 119 

neuralgia of, 147 

palpation of, 122 

percussion of, 122 
Heart-sounds, accentuation of, 123 



Heart-sounds — 

reduplication of, 124 

weakness of, 124 
Hemiansesthesia, causes of, 320 
Hemi-atrophy, facial, 403 
Hemicrania, 374 
Hemiplegia, causes of, 311 
Hemorrhage, cerebral, 341 

broncho-pulmonary, 198 

from the intestines, 22 

from the kidneys, 93, 94 

from the lungs, 198 

from the nose, 154 

from the stomach, 45 
Hepatitis, acute, 80 

catarrhal, 73 

interstitial, chronic, 77 
Herpes iris, 440 

simplex, 438 

zoster, 439 
Hiccough, causes of, 21 
Hives, 437 

Hodgkin's disease, 115 
Hydatids of the liver, 83 
Hydrocephalus, 334 

acute, 331 
Hydronephrosis, 106 
Hydrophobia, 288 
Hyperaemia, cerebral, 339 

hepatic, 76 

pulmonary, 200 

renal, 95 
Hyperaesthesia, causes of, 320 
Hyperidrosis, 430 
Hypertrichosis, 470 
Hypertrophy, cardiac, 143 

pseudo-muscular, 370 
Hysteria, 391 



ICHTHYOSIS, 469 
1 Icterus, 71 
Icterus neonatorum, 72 
Ileus, varieties of, 59 
Illusion, 329 
Impetigo, 455 

contagiosa, 456 
Impulse, morbid, 329 
Incubation, periods of, 233 
Indican, test for, 94 
Indicanuria, causes of, 94 



496 



INDEX. 



Influenza, 280 

Insane, general paralysis of, 336 

Inspection of the chest, 163 

of the praecordia, 119 
Intestinal obstr action, 59 
Intussusception, 60 
Invagination, 60 
Itch, 488 

barbers', 486 



AUNDICE, catarrhal, 73 
causes of, 71, 72 
haematogenous, 72 
hepatogenous, 71 
malignant, 84 
non-obstructive, 72 
obstructive, 71 
varieties of, 71 



KIDNEY, amyloid degeneration of, 
102 
congestion of, 95 
diseases of, 85 
floating, 107 
gouty, 100 
inflammation of, acute, 97 

chronic, 99, 100 
large white, 99 
movable, 107 
red granular, 100 
stone in, 103 
waxy, 102 
Keloid, 473 
Keratosis pilaris, 465 
Knee-jerk, 318 

causes which diminish. 318 
which increase, 318 



T A GRIPPEE, 280 
J j Landry's disease, 367 
Laryngismus stridulus, 179 
Laryngitis, 173 
Larynx, oedema of, 181 
Lead-poisoning, chronic, 411 
Lentigo, 464 
Lepra, 480 

Leptomeningitis, cerebral, 333 
spinal, 352 



Leucin in the urine, 87 
Leucocythaemia, 114 
Leucocytosis, 109 
Leucoderma, 478 
Lichen planus, 449 

ruber, 449 

scrofulosis, 449 
Lipaemia, 111 
Lithaemia, 303 
Lithuria, 86 
Liver, abscess of, 80 

acute yellow atrophy of, 84 

amyloid, 82 

cancer of, 81 

cirrhosis of, 77 

consistence of, 70 

diminution in the size of, 71 

echinococcus of, 83 

enlargement of, irregular, 71 
uniform, 71 

hydatids of, 83 

hyperaemia of, 76 

inflammation of, 73, 77, 80 

palpation of, 70 

percussion, 71 

pulsation of, 71 
Localization, cerebral, 348 
Lockjaw, 286 
Locomotor ataxia, 357 
Lumbago, 295 
Lungs, abscess of, 213 

cirrhosis of, 211 

collapse of, 215 

congestion of, 200, 201 

gangrene of, 212 

infarction of, 199 

oedema of, 215 
Lupus erythematosa, 475 

vulgaris, 476 



MACROCYTOSIS, 110 
Macules, causes of, 417 
Malaria, haematozoa of, 251 
malignant, 253 
' Malarial cachexia, 250 

fever, 254 
Mania a potu, 408 
Measles, 260 

German, 262 
Melaena (see Enirorrhagia), 22 



INDEX. 



497 



Melanaeniia, 110 
Meniere's disease, 390 
Meningitis, cerebral, 331, 333, 334 

epidemic cerebrospinal, 247 

spinal, 352 

tuberculous, 331 
Meningoencephalitis, chronic, 336 
Mensuration of the chest, 169 
Microeytosis, 110 
Migraine, 374 
Miliaria, 457 
Milium, 434 

Mitral diseases, 136, 137 
Molluscum epitheliale, 466 
M on anaesthesia, causes of, 321 
Monoplegia, causes of, 311 
Morbilli, 260 

Morbus macnlosus Werlhofii, 117 
Mor van's disease, reference to, 363 
Mouth, diseases of, 23 
Mucin, spiral of, in sputum, 158 
Multiple neuritis, 381 
Mumps, 281 
Murmur, respiratory, modifications 

of, 166 
Murmurs, aneurismal, 125 

cardiac, 124 

haemic, 124 
Muscular contraction, paradoxical, 

320 
Myalgia, 295 
Mydriasis, causes of, 327 
Myelitis, 354 
Myocarditis, 142 
Myosis, causes of, 327 
Myotonia, congenital, 401 
Myxoedema, 324, 404 



N^EVUS pigmentosa, 469 
Nails, atrophy of, 417, 480 
curving of, 417 
Nasal catarrh, 171 
Nematodes, 63 
Nephritis, acute, 97 
catarrhal, 97 
parenchymatous, 97 
chronic catarrhal, 99 
interstitial, 100 
Nephrolithiasis, 103 
Neuralgia, 371 
32 



Neurasthenia, 395 
Neuritis, 379 

multiple, 381 
Nose, red, causes of, 153 
Nutrition, disturbances of, 322 
Nystagmus, 328 



OBSTRUCTION, intestinal, 59 
(Edema, causes of, 416 

acute, angio-neurotic, 404 
of the larynx, 181 
of the lungs, 214 

(Esophageal obstruction, varieties 
of, 31 

CEsophagisnms, 32 

Oligocythemia, 109 

Onychauxis, 470 

Onychia, 417 

Opium-poisoning, 410 

Oxalates in the urine, 89 

Oxybutyria, causes of, 93 

Oxybutyric acid, test for, 93 

Oxyuris vermicularis, 64 

Ozena, 172 



PACHYMENINGITIS, cerebral, 333 
hemorrhagic, 334 

spinal, 353 
Palpation of the chest, 163 

of the heart, 122 
Palpitation, 128 
Palsy, 310 

Bell's, 383 

bulbar, 367 

hysterical, 391 

shaking, 398 
Pancreas, diseases of, 69 
Papules, cutaneous, causes, 424 
Paresthesia. 322 
Paralysis, acute ascending, 367 

agitans, 398 

atrophic spinal, 363 

causes of, 310 

cerebral, in children, 338 

divers', 368 

glosso-labio-laryngeal . 367 

infantile, 363 

laryngeal, 155 

pseudo-hypertrophic, 370 



498 



LN'DEX. 



Paramyoclonus multiplex, 316 
Paraplegia, ataxic, 361 

causes of, 312 

primary spastic, 360 
Parasites, intestinal, 62 
Paretic dementia, 336 
Parosmia, 154 
Parotitis (see Mumps), 281 
Pectoriloquy, 167 
Pediculosis, 489 
Pemphigus, 454 
Percussion immediate, 164 

mediate, 164 

of tlie heart, 122 

of the lungs, 164 
Pericarditis, 130 
Pericardium, adherent, 131 

air in, 133 

blood in, 133 

dropsy of, 132 
Peritonitis, 66 
Perityphlitis, 58 
Pernicious anaemia, 112 
Pertussis, 278 
Petechia?, causes of, 418 
Pharyngitis, 30 
Phosphates in the urine, 88 
Phthisis, 216 

acute, 212, 219 

fibroid, 219 

chronic ulcerative, 217 
Pica, 19 
Pleurisy, acute, 224 

diaphragmatic, 225 

fibrinous, 225 

hemorrhagic. 224 

purulent, 225 

tuberculous, 225 
Pleurodynia, 295 
Plumbism, 411 
Pneumonia, alcoholic, 204 

broncho-, 207 

catarrhal, 207 

chronic interstitial, 211 

croupous, 202 

hypostatic, 201 

in children, 204 

lobar, 202 

senile, 204 

typhoid, 204 
Pneumopericardium, 133 



Pneumothorax, 227 

hydro-, 227 

pyo-, 227 
Poikilocytosis, 109 
Poisoning, arsenical, chronic, 413 

lead, chronic, 411 

mercurial, chronic, 412 

opium, 410 
Poliomyelitis, acute anterior, 363 

chronic, 365 
Polyuria, causes of, 85 
Pompholyx, 465 

Progressive muscular atrophy, 363 
Prurigo. 450 
Pruritus, 484 
Pseudo-leukaemia, 115 
Pseudo-muscular hypertrophy, 370 
Psoriasis, 444 
Ptyalism, 25 

Pulmonary valve, affections of, 138 
Pulsation, abnormal centres of, 121 
Pulse, bigeminal, 126 

Corrigan's, 128 

dicrotic, 127 

high-tension, 127 

increased frequency of, 126 

intermittent, 126 

irregular, 126 

jugular, 128 

low-tension, 128 

trigeminal, 126 

venous, 128 

water-hammer, 128 
Pulses, asymmetrical radial, 128 
Pulsus paradoxus, 127 
Purpura hemorrhagica, 117 
Purpuric rashes, causes of, 418 
Pus in the expectoration, 157 

in the stools, 22 

in the urine, 95 

in the vomit, 20 
Pustules, causes of, 422 
Pyelitis, 105 
Pyelonephritis, 105 
Pylorus, obstruction of, 43 
Pyonephrosis, 105 
Pyrexia, 230 
Pyuria, causes of, 95 



Q 



UINSY, 26 



INDEX. 



499 



RABIES, 288 
Rachitis, 302 
Riles, 16S 

Rashes, time of appearance of, 283 
Raynaud's disease, 403 
Reflexes, deep, theory of, 318 

causes which diminish, 318 
which increase, 318 
superficial, 319 
Relapsing fever, 245 
Remittent fever, 252 
Renal calculus 104 
colic, 104 
congestion, 95 
Resonance, pulmonary, diminished, 
165 
increased, 164 
outlines of, 164 
vocal, diminution of, 167 
increase of, 167 
Respiration, normal, 166 

disturbances of, 156, 166 
Respiratory murmur, modifications 

of, 166 
Retro-pharyngeal abscess, 30 
Rheumatism, acute articular, 290 
chronic, 294 
inflammatory, 290 
muscular, 295 
Rheumatoid arthritis, 300 
Rhinitis, 170 
Rickets, 302 
Ringworm, 485 
Romberg's symptom, 358 
Rose cold, 194 
Roseola, epidemic, 262 
Rotheln, 262 
Rubella, 262 
Rubeola. 260 



SALAAM convulsions, 315 
Salivation (see Mercurial Stoma- 
titis), 25 
Sarcinse ventriculi, 44 
Scabies, 488 
Scales, cutaneous, diseases which 

cause, 427 
Scarlatina, 256 
Scarlet fever, 256 
Sciatica, 383 



Scleroderma, 470 
Sclerosis, spinal, 357 

amyotrophic lateral, 360 

disseminated, 361 

lateral, 360 

multiple, 361 

posterior, 357 
Scorbutus, 117 
Scurvy, 117 
Seborrhcea, 432 

Sensation, disturbances of, 320 
Sense, muscular, 322 
Senses, special, disturbances of, 327 
Sensibility, muscular, 322 
Skin, discoloration s of, 414 

glossy, 416 

hardness of, 414 

pallor of, 414 
Smallpox, 263 

Smell, sense of, disturbances of, 154 
Softening, cerebral, 346 
Somnambulism, 327 
Sound, cracked-pot, 165 
Sounds, adventitious pulmonary, 168 
Spasm, laryngeal, 154 

oesophageal, 32 

saltatory, 315 
Spinal cord, sclerosis of, 357 
Sputum, Charcot-Leyden crystals in, 
159 

currant-jelly, 157 

elastic fibre in, 158 

fatty acids in, 159 

fetid, 157 

fibrinous shreds in, 157 

hsematoidin in, 159 

microscopy of, 158 

mucin in, 158 

muco-purulent, 158 

prune-juice, 157 

purulent,. 158 

rusty, 157 

spirals, Curschmamrs, in, 192 

tubercle bacilli in, 159 
Stenocardia, 147 
Stomach, cancer of, 42 

dilatation of, 43 

inflammation of, 33, 37 

neuralgia of, 39 

ulcer of, 40 
Stomatitis, 24 * 



500 



INDEX. 



Stools, changes in, in disease, 22 
Steatoma, 435 
Stricture, intestinal, 61 

oesophageal, 31 

pyloric, 43 
St. Vitus's dance, 396 
Succussion-splash, 169 
Sudamen, 431 
Sugar in the urine, 90 

tests for, 90, 91 
Sunstroke, 406 

Swallowing, difficult, causes of, 19 
Sweat-glands, diseases of, 430 
Sycosis, simple, 462 

tinea, 486 
Syphilis cutanea, 478 
Syringo-rnyelia, 363 



TABES dorsalis, 357 
Tachycardia, 125 
Tsenia mediocanellata, 62 

saginata, 62 

solium, 62 
Tape-worm, Varieties of, 62 
Teeth, Hutchinson's, 17 
Temperature, subnormal, causes of, 

235 
Tetanus, 282 
Tetany, 400 

Thermo-ansesthesia. 321 
Thomsen's disease, 401 
Thrills, cardiac, causes of, 122 
Thrombosis, cerebral, 345 
Thrush, 24 
Tic douloureux, 372 
Tinea circinata, 486 

favosa, 488 

sycosis, 486 

tonsurans, 485 

versicolor, 487 
Tinkling, metallic, 169 
Tinnitus aurium, causes of, 328 
Titubation, 318 
Tongue, condition of, in disease, 17 

scars on, 18 

tremor of, 18 
Tonsillitis, 26 
Tonsils, hypertrophy of, 28 
Trance, 327 
Tremors, causes of. 317 



Trichina spiralis, 64 
Trichinosis, 64 
Tricocephalus dispar, 64 
Tricuspid valve, diseases of, 138 
Tumors, cerebral, 347 

intestinal, 61 
Tubercle bacillus, detection of, 159 
Tuberculosis, acute general, 272 

meningeal, 331 

pulmonary, 216 
Tubercules, cutaneous, causes of, 425 
Typhlitis, 58 
Typhoid fever, 237 
Typhus fever, 243 
Tyrosin in the urine, 87 



ULCER, gastric, 40 
perforating, of the foot, 325 
Ulcers, cutaneous, causes of, 428 
Uraemia, 96 
Urates, increase of, 87 
Urea, diminution of, 86 

increase of, 86 

test for, 86 
Uric acid, test for, 86 
Urine, albumin in, 92 

bile in, 94 

blood in, 93 

chlorides in, 89 

chyle in, 94 

diminution of, 85 

increase of, 85 

indican in, 94 

leucin in, 87 

oxalates in, 89 

phosphates in, 88 

pus in, 95 

sugar in, 90 

tyrosin in, 87 

urea in, 86 

uric acid in, 86 
Urobilinuria, 90 
Urticaria, 437 



VACCINIA, 267 
Vagabond ismus, 415 
Valvular affections of the heart, 135 
Varicella, 266 
Variola, 263 



INDEX. 



501 



Varioloid, 265 

Verruca, 468 

Vertigo, 389 

Vesicles, cutaneous, causes of, 420 

Vitiligo, 458 

Vocal cords, paralysis of, 155 

Voice, loss of, 154 

Vomit, varieties of, 20 

Vomiting, causes of, 20 



WART, 468 

TT Wheals, causes of, 426 
Whooping-cough, 278 
Worms, intestinal, 62 



Writers' cramp, 400 
Wry-neck, 295 



X 



ANTHOMA, 474 



VELL 



OW fever, 270 



yOSTKR, herpes, 439 



CATALOGUE 



I ^Epfec!^ SURGICAL 



'•v. *- N 




°n C . 






3 ,Ct, ° nary of 4! >e N °W r? a 

| PHILADELPHIA^ /V ^°^ 

._ — ^. — 

o 

— The aim of the publisher of the works described in the 

m following pages has been to make them of permanent and 

S not transient value to students and members of the medical 

P 

© profession. They are all written or edited by well-known 

and competent authors, many of international repute. 

2 Especial care has been exercised in the selection of clear, 

2 readable type, high class illustrations, good paper, and 

„ serviceable bindings. 



* * 



For sale by Booksellers in all principal cities of the 
United States and Canada ; or sent post free on receipt of 
price by the Publisher. 



MR. SAUNDERS takes pleasure in announcing to the 
medical profession the preparation of 



AN 



American Text-Book of Surgery. 



GENERAL AND OPERATIVE. 
Price, Cloth, $7.00; Sheep, $8.00. 

BY 

W, W. KEEN, M.D., LL.D., 

Professor of the Principles of Surgery and of Clinical Surgery in the 
Jefferson Medical College of Philadelphia. 

J. WILLIAM WHITE, M.D., Ph.D., 

Professor of Clinical Surgery in the University of Pennsylvania. 



P. S. CONNER, M.D., LL.D., 

Professor of Surgery and Clinical Surgery in the Medical College of Ohio, 
Cincinnati, Ohio. 

FREDERIC S. DENNIS, M.D., 

Professor of the Principles and Practice of Surgery and Clinical Surgery 
in Bellevue Hospital Medical College, New York. 

CHARLES B. NANCREDE, M.D., 

Professor of Surgery in the University of Michigan, Ann Arbor, Michi- 
gan. 

ROSWELL PARK, M.D., 

Professor of Surgery in the Medical Department of the University of 
Buffalo, New York. 

LEWIS S. PILCHER, M.D., 

Professor of Clinical Surgery in the Post-Graduate Medical School, New 
York. 

N. SENN, M.D., Ph.D., 

Professor of Surgery in Rush Medical College, Chicago, and in the Chi- 
cago Polyclinic. 






FRANCIS J. SHEPHERD, M.D., 

Professor of Anatomy and Lecturer in Operative Surgery, McGill Uni- 
versity, Montreal, Canada. 

LEWIS A. STIMSON, M.D., 

Professor of Surgery in the University of New York. 

J. COLLINS WARREN, M.D., 

Associate Professor of Surgery in Harvard University. 



CHARLES H. BURNETT, M.D., 

Professor of Otology in the Philadelphia Polyclinic and College for Gradu- 
ates in Medicine. 

WILLIAM THOMSON, M.D., 

Professor of Ophthalmology in the Jefferson Medical College, Philadel- 
phia. 

Recognizing the fact that for a number of years there 
has been an increasing demand for a text-book on Surgery 
which should be at once concise and comprehensive, and 
at the same time essentially American in its teachings, the 
various authors have undertaken the preparation of such 
a work, which, INSTEAD of embodying the ideas of a single 

INDIVIDUAL, WILL BE COMPOSED OF A SERIES OF TREATISES, 
EACH WRITTEN BY A TEACHER OF SURGERY, BUT COMBINED 
INTO A SINGLE AUTHORITATIVE WORK BY MUTUAL CRITICISM 
AND REVISION. 

It is intended in this manner to obtain the undoubted 
benefit of the special knowledge and experience of the 
different authors in their respective lines of work, while 
avoiding all unnecessary detail. The book as a whole will 
thus faithfully represent the prevailing views and methods 
of American surgeons. 

The names and professional positions of the authors in- 
dicate without further explanation the general scope and 
character of the work. 

It will form a handsome royal octavo volume, printed in 
beautiful large clear type, on heavy paper, with numerous 

FINE ILLUSTRATIONS. 
3 



Now in Preparation for Publication in Early Fall of 1892. 
A TREATISE 

ON THE 

Theory and Practice of Medicine. 

BY 

AMERICAN TEACHERS 



ETHTED BY 



WILLIAM PEPPER, M.D., LL.D., 

Provost and Professor of the Theory and Practice of Medicine and of 
Clinical Medicine. 



To be completed in two Handsome Royal Octavo Volumes of 
about 1000 pages each, with Illustrations to Eluci- 
date the Text wherever Necessary. 



Price per Volume, Cloth, $5.00 ; Sheep, $0.00; 
Half Russia, $7.00. 



ASSOCIATE AUTHORS. 

J. S. BLLLINGS, M.D., 

Professor of Hygiene, University of Pennsylvania. 

FRANCIS DELAFIELD, M.D.. 

Professor of Pathology and Practice of Medicine, Colh ge of Physicians 
and Surgeons, New York City. 

TR. H. FITZ, M.D., 

Shattuck Professor of Pathological Anatomy, Harvard Medical School. 

JAMES W. HOLLAND, M.D., 

Professor of Medical Chemistry and Toxicology, Jefferson Medical Col- 
lege, Philadelphia. 

4 



E. G. JANEWAY, M.D., 

Professor of Principles and Practice of Medicine, Bellevue Hospital Med- 
ical College, New York City. 

HENRY M. LYMAN, M.D., 

Professor of Principles and Practice of Medicine, Rush Medical College, 
Chicago, 111. 

WILLIAM OSLER, M.D., 

Professor of Practice of Medicine, Johns Hopkins University, Balti- 
more, Md. 

W. GILMAN THOMPSON, M.D., 

Professor of Physiology, New York University Medical College. 

W. H. WELCH, M.D., 

Professor of Pathology, Johns Hopkins University, Baltimore, Md. 

JAMES T. WHITTAKER, M.D., 

Professor of the Theory and Practice of Medicine and Clinical Medicine, 
Medical College of Ohio. Cincinnati, Ohio. 

JAMES C. WILSON, M.D., 

Professor of Practice of Medicine and Clinical Medicine, Jefferson Med- 
ical College, Philadelphia. 

HORATIO C. WOOD, M.D., 

Professor of Materia Medica, Pharmacy, and General Therapeutics, and 
Clinical Professor of Nervous Diseases, University of Pennsylvania. 

This, the latest work on a most important subject, will 
contain in a comparatively small space the experience and 
teachings of a number of the best-known Medical Men of 
America, presented in a terse, practical, and authoritative 
style. Especial prominence will be given to Symptomatol- 
ogy, Diagnosis, Prognosis, and Treatment, other sections 
receiving attention in proportion to their importance. 

Under the head of Treatment, a large number of Form- 
ulae will be given by each author. 

It will.be issued in two handsome Royal Octavo volumes 
of about 900 pages each, with very complete Indices, 
printed on heavy paper, from good, clear t}-pe, with Illus- 
trations to elucidate the text wherever necessary. 



Now Ready— Second Revised Edition. 



MEDICAL DIAGNOSIS. 



BY 

5 DR. OSWALD VIERORDT, 

© Professor of Medicine at the University of Heidelberg, formerly Privat 

5 Docent at University of Leipzig, Professor of Medicine and Director 

«a of the Medical Polyclinic at the University of Jena. 

•^ 
*5 

£ Translated, with Additions, from the Second Enlarged German 

*2 Edition, with the Author's Permission, 

§ BY 

1 FRANCIS H. STUART, A.M., M.D., 

to 

2 Member of the Medical Society of the County of Kings, New York, 
g Fellow of the New York Academy of Medicine, Member of the 
< British Medical Association, etc. 

In one handsome royal octavo volume of 700 pages. 

§ 178 fine wood-cuts in text, many of which are in colors. 

** Price, Cloth, $4.00 net; Sheep, $5,00 net. 

J 8 



THIS VALUABLE WORK IS NOW PUBLISHED IN GERMAN, ENGLISH, RUSSIAN, 
AND ITALIAN. 



£ This important accession to the text-books of 1891 will be wel- 
^ corned by both the Student and the Practitioner, giving, as it does, 
"t in a eoncise and clear manner, the experience of one of Germany's 
<^ most profound scholars and specialists in this branch of the practice 
g of medicine. 

^h In this work, as in no other hitherto published upon the subject, 

are given full and accurate explanations of the phenomena observed 

ac at the bedside. It is distinctly a clinical work by a master teacher, 

.$» characterized by thoroughness, fulness, and accuracy. It is a mine 

j^! of information upon the points that are so often passed OV er without 

explanation. The student who is familiar with its contents will 

have a sound foundation for tne practice of his profession. 

The author gives a complete, though brief, presentation of the 
micro-organisms whose recognition and discrimination are made 
possible by cultivation and inoculation, and which, through the 
labors of those eminent bacteriologists — Pasteur, Koch, and others 
— havp already made such a marked change in the application of 
remedial agents in the cure of disease. 






rixro-w- H.!E.<A.:E>Y. 

A NEW 

Pronouncing Dictionary of Medicine. 



JOHN M. KEATING, M.D., 

Fellow College of Physicians of Philadelphia ; Visiting Obstetrician to the 
Philadelphia Hospital, and Lecturer on Diseases of AVomen and Chil- 
dren ; Gynaecologist to St. Joseph's Hospital ; Surgeon to 
the Maternity Hospital, etc.; Editor " Cyclo- 
paedia of Diseases of Children," 



HENRY HAMILTON, 

Author of " A New Translation of Virgil's iEneid into English Rhyme ; 
Co-author of "Saunders' Medical Lexicon," etc. 

Price, Cloth, $5.00; Sheep, $6.00. 



A voluminous and exhaustive handbook of 

Medical, Surgical, and Scientific Terminology, 

containing concise explanations of the various terms used in Medicine 
and the allied sciences, with 

Phonetic Pronunciation, Accentuation, Etymology, etc. 

The work will form a very handsome royal 8vo volume, beautifully 
printed from type specially cast for the work, on paper manufactured for 
this purpose. It will contain most important tables of 

Bacilli, Micrococci, Leucomaines, Ptomaines, etc. etc., 

the whole forming the most complete, reliable, and valuable Diction- 
ary in the market. 

It has been the aim of the Publisher to place in the hands of stu- 
dents and the medical profession a work which should contain the 
names of Hundreds of New Words now being adopted, and at the same 
time, by leaving out the numerous obsolete terms contained in most Dic- 
tionaries, keep the volume of such a size as to be most convenient for 
ready reference. 



POCKET MEDICAL LEXICON; 

OR, 

Dictionary of Terms and Words used in Medicine and Surgery. 

By JOHN M. KEATING, M.D., 

Editor of "Cyclopaedia of Diseases of Children," etc. ; Author of the 
"New Pronouncing Dictionary of Medicine," 



HENRY HAMILTON, 



Author of "A New Translation of Virgil's iEneid into English Verse : 
Co-author of a "New Pronouncing Dictionary of Medicine." 



Price, 75 Cents, Cloth. $1,00, Leather Tucks. 



of water: J' v " 

SO _ 

do 

70 —. 
60 — 
SO 
40 
JO 

to —I 



/O — 



if water: / 



^/76 



fS8 



212° —.80* 



191 _ 72 



/to 



J 22 



./04 



86 



— 69 



— 64 

— 56 

— 48 

— 40 

— 32 

— & 

— 76 



This new and comprehensive 
work of reference is the outcome 
of a demand for a more modern 
handbook of its class than those 
at present on the market, which, 
dating as they do from 1S55 to 
1884, are of but trifling use to 
the student by their not con- 
taining the hundreds of new 
words now used in current lit- 
erature, especially those relat- 
ing to Electricity and Bacteri- 
ology. 



SO —8 



Annals of Gynecology, Phila- 
delphia, December, 1890. 



.32* —O l 



74 — 



Saunders' Pocket Medical Lexi- 
con—a very complete little work, 
invaluable to every student of 
medicine. It not only contains a 
very large number of words, but 
— tS' als0 tables of etymological factors 
common in medical terminology ; 
abbreviations used in medicine, 
(From Appendix to Medical Lexicon.) poisons and antidotes, etc. 

a 



o 






JSow Ready— Fourth Edition. 

CONTAINING 

zEmsrxs oisr dissection/ 



Essentials of Anatomy and Manual of Practical 
Dissection. 

By CHARLES B. NANCKEDE, M.D., 

Professor of Surgery and Clinical Surgery in the University of Michigan, Ann 

Arbor; Corresponding Member of the Eoyal Academy of Medicine, 

Borne, Italy; late Surgeon Jefferson Medical College, etc. etc. 



With Handsome Fall-page Lithographic Plates in Colors.^ Over 200 Illustrations. 

No pains or expense has been spared to make thi%work the most exhaustive 
yet concise Student's Manual of Anatomy and Dissection ever published, either 
in this country or Europe. 

The colored plates are designed to aid the student in dissecting the muscles, 
arteries, veins, and nerves. For this edition the woodcuts have all been speci- 
ally drawn and engraved, and an Appendix added containing 60 illustrations 
representing the structure of the entire human skeleton, the whole based on 
the eleventh edition of Gray's Anatomy, and forming a handsome post 8vo 
volume of over 400 pages. 




Price, Extra Cloth or Oilcloth for the Dissection-Room, $2.00 Net. 
Medical Sheep, 2.50 " 

Times and Register, Philadelphia, August 23, 1S90.— Nancrede's Anatomy 
and Dissector— this is a good dissector's manual, with clear type and hand- 
some cuts. The colored plates are especially commendable. 

9 



NOW READY 



DISEASES OF THE EYE. 

A HAND-BOOK OF OPHTHALMIC PRACTICE. 
By G. E. de SCHWEIXITZ, M.D., 

Ophthalmic Surgeon to Children's Hospital and to the Philadelphia Hospital 

Ophthalmologist to the Orthopaedic Hospital and Infirmary for Xer- 

vous Diseases ; Lecturer on Medical Ophthalmoscopy, 

University of Pennsylvania, etc. 



Porming a handsome royal 8vo. volume of more than 600 pages. 

Over 200 fine wood-cuts, many of which are original, and two 

chromo-lithograpic plates. 

Brice, Cloth, $4.00; Sheep, $5.00. 



The object of this manual is to present to the student who is be- 
ginning work in the field of ophthalmology a plain description of 
the optical defects and diseases of the eye. To this end special 
attention has been paid to the clinical side of the question ; and the 
methods of examination, the symptomatology leading to a diagnosis, 
and the treatment of the various ocular defects have been brought 
into special prominence. Anatomy, physiology, and pathological 
histology, except in so far as they serve the purpose just stated, 
have been omitted. The sections devoted to optical principles and 
the normal and abnormal refraction of the eye in large portion have 
been written by Dr. James Wallace, Chief of the Eye"Dispensary ol 
the University Hospital. The chapter devoted to the application 
of the shadow-test has been prepared by Dr. Edward Jackson. The 
book will be suitably illustrated by a number of wood-cuts, many of 
them from cases in the practice of the author, in addition to which 

there will be several chromo-lithographs. 

10 



IN PREPARATION. 



DISEASES OF WOMEN. 

By HENRY J. GARRIGUES, A.M., M.D., 

Professor of Obstetrics in the New York Post-Graduate Medical School and 
Hospital ; Gynaecologist to St. Mark's Hospital in New York City ; Gynge- 
cologist to the German Dispensary in the City of New York; Con- 
sulting Obstetrician to the New York Infant Asylum; Obstetric 
Surgeon to the New York Maternity Hospital ; Fellow of 
the American Gynaecological Society ; Fellow of the 
New York Academy of Medicine ; President of the 
German Medical Society of the City of New 
York, etc. etc. 

It is the intention of the writer to provide a practical manual on 
Gynaecology, for the use of students and practitioners, in as concise a 
manner as is compatible with clearness. 






Syllabus of Obstetrical Lectures 

In the Medical Department, University of Pennsylvania. 

By RICHARD C. NORRIS, A.M., M.D., 

Demonstrator on Obstetrics in the University of Pennsylvania. 

Second Edition thoroughly revised and enlarged. 

Price, Cloth, Interleaved for Notes . . . $2.00 Net. 

The New York Medical Record of April 19, 1890, referring to this 
book, says : " This modest little work is so far superior to others on 
the same subject that we take pleasure in calling attention briefly to 
its excellent features. Small as it is, it covers the subject thoroughly, 
and will prove invaluable to both the student and the practitioner as 
a means of fixing in a clear and concise form the knowledge derived 
from a perusal of the larger text-books. The author deserves great 
credit for the manner in which he has performed his work. He has 
introduced a number of valuable hints which would only occur to one 
who was himself an experienced teacher of obstetrics. The subject- 
matter is clear, forcible, and modern. We are especially pleased with 
the portion devoted to the practical duties of the accoucheur, care of 
the child, etc. The paragraphs on antiseptics are admirable ; there 
is no doubtful tone in the directions given. No details are regarded 
as unimportant ; no minor matters omitted. We venture to say that 
even the old practitioner will find useful hints in this direction which 
he cannot afford to depise." 

11 



JUST READY. 



SAUNDERS' 

Pocket Mical Formulary. 

BY 

WILLIAM M. POWELL, M. D., 

Attending Physician to the Mercer House for Invalid Women, at Atlantic City. 

N. J. ; Late Physician to the Clinic for the Diseases of Children in the 

Hospital of the University of Pennsylvania and St. Clement's 

Hospital; Instructor in' Physical Diagnosis in the Medical 

Department of the University of Pennsylvania, and 

Chief of the Medical Clinic of the Philadelphia 

Polyclinic. 



Containing 1750 Formulae,- selected from several hundreds 
of the best-known authorities. 



Forming a Handsome and Convenient Pocket Companion of 

about 275 printed pages, with blank leaves^for additions. 

Handsomely bound in Morocco, with side index, 

wallet and flap. 



ZF^iaiE, $1.75 1TETT. 

A concise, clear, and correct record of the many hundreds of famous 
formulae which are found scattered through the works of the 

Most Eminent Physicians and Surgeons 

of the world; particularly helpful to the student and young practitioner, 
as it gives him a taste for writing his prescriptions in an elegant and 
correct manner, thus avoiding incompatible and dangerous prescriptions. 
The use of this work is to be recommended even to the older prac- 
titioner, as through it he becomes acquainted with numerous formula: 
which are not found in text-books, but have been collected from among 
the 

Rising Generation of the Profession, College Professors, and 
Hospital Physicians and Surgeons. 

12 



NOW BEADY. 



NEW AND REVISED EDITIONS OF 

SAUNDERS' 

QUESTION COMPENDS. 

Arranged in Question and Answer Form. 

The Latest, Cheapest, and Best 

ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. 



THE ADVANTAGES OF QUESTIONS AND 

ANSWERS. — The usefulness of arranging 1 the subjects in 
the form of Questions and Answers will be apparent, 
since the student, in reading the standard works, often is at 
a loss to discover the important points to be remembered, 
and is equally puzzled when he attempts to formulate ideas 
as to the manner in which the Questions could be put 
in the Examination-Room. 



These small works, which can be conveniently carried in the pocket, 
contain in a condensed form the teachings of the most popular 
text-books. 

The authors are nearly all connected with the various colleges as 
Demonstrators or Lecturers, and are therefore thoroughly conver- 
sant, not only with the wants of the average student, but also with 
the points that are absolutely necessary to be remembered in 
the Examination-Room. These books are constantly in the hands 
of their authors for revision, and are kept well up to the times, their 
fast sale allowing them to be almost entirely rewritten ■whenever 
necessary, instead of having to wait for the edition to be sold, as is 
the case with an ordinary text-book. 

13 



No. 1. 



ESSENTIALS OE PHYSIOLOGY. 



H. A. HARE, M.D., 

Professor of Therapeutics and Materica Medica in the Jefferson Medical Col- 
lege of Philadelphia; Physician to St. Agnes' Hospital and to the 
Medical Dispensary of the Children's Hospital ; Laureate of 
the Royal Academy of Medicine in Belgium, of the 
Medical Society of London, etc. ; Secretary 
of the Convention for the Revision of 
the Pharmacopoeia, 1890. 



NUMEROUS ILLUSTRATIONS. 

Third Edition, revised and enlarged by the addition of a series of 

handsome plate illustrations taken from the celebrated 

" Icones Nervorum Capitis " of Arnold. 

Price, Cloth, $1.00 net. Interleaved for notes, $1.25 net. 




Specimen of Illustrations. 



University Medical Magazine, 
October, 1888.— " Dr. Hare has 
admirably succeeded in gather- 
ing together a series of Ques- 
tions which are clearly put and 
tersely answered." 

Pacific Medical Journal, Octo- 
ber, 1889.—" Hare's Physiology 
contains the essences of its sub- 
ject. No better book has ever 
been produced, and every stu- 
dent would do well to possess a 
copy." 

Times and Register, Philadel- 
phia, October 5, 1889.—" In the 
second edition of Hare's Physi- 
ology all the more difficult points 
of the study of the nervous sys- 
tem have been elucidated. As 
the work now appears it cannot 
fail to merit the appreciation of 
the overworked student." 



14 






No. 2. 



ESSENTIALS OF SURGERY. 



CONTAINING, ALSO, 

Venereal Diseases, Surgical Landmarks, Minor and Operative Sur- 
gery, and a Complete Description, together with full Illustra- 
tions, of the Handkerchief and Roller Bandage. 

By EDWARD MARTIN, A.M., M.D., 

Clinieal Professor of Genito-Urinary Diseases, Instructor in Operative Sur 

gery, and Lecturer on Minor Surgery, University of Pennsylvania; 

Surgeon to the Howard Hospital ; Assistant Surgeon to the 

University Hospital, etc. etc. 



PROFUSELY ILLUSTRATED. 

FOURTH EDITION, 
Considerably enlarged by an Appendix containing full directions 
and prescriptions for the preparation of the various mate- 
rials used in ANTISEPTIC SURGERY ; also sev- 
eral hundred recipes covering the medical 
treatment of surgical affections. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

Medical and Surgical Reporter, 
February, 1889. — " Martin's Sur- 
gery contains all necessary essen- 
tials of modern surgery in a com- 
paratively small space. Its style 
is interesting and its illustrations 
admirable." 

University Medical Magazine, 
January, 1889. — "Dr. Martin has 
admirably succeeded in selecting 
and retaining just what is neces- 
sary for purposes of examination, 
and putting it in most excellent 
shape for reference and memor- 
izing." 

Kansas City Medical Record. — 
" Martin's Surgery. — This admir- 
able compend is well up in the 
most advanced ideas of modern 
surgery." 




Specimen of Illustrations. 



15 



No. 3. 

ESSENTIALS OF ANATOMY, 

Including the Anatomy of the Viscera. 

By CHARLES B. NANCREDE, M.I)., 

Professor of Surgery and Clinical Surgery in the University of Michigan, 

Ann Arbor ; Corresponding Member of the Royal Academy of 

Medicine, Rome, Italy ; Late Surgeon Jefferson 

Medical College, etc. etc. 

ONE HUNDRED AND FORTY FINE WOODCUTS 

THIRD EDITION. 

Enlarged by an Appendix containing over Sixty Illustrations of 

the Osteology of the Human Body. 

The -whole based upon the last (eleventh) edition of 

GRAY'S ANATOMY. 

Price, Cloth, $1.00. Interleayed for Notes, $1.25. 

American Practitioner and 
News, February 16, 1889. 

" Nancrede's Anatomy. — 
For self-quizzing and keep- 
ing fresh in mind the 
knowledge of Anatomy 
gains at school, it would 
not be easy to speak of it 
in terms too favorable." 

Southern Califorman Practi- 
tioner, January 18, 1889. 
" Nancrede's Anatomy. — 
Very accurate and trust- 
worthy." 

American Practitioner and 
News, Louisville, Kentucky. 
" Nancrede's Anatomy. — 
Truly such a book as no 
student can afford to be 
without." 




Specimen of Illustrations. 



16 






No. 4. 



Essentials of Medical Chemistry 



ORGANIC AND INORGANIC. 



CONTAINING, ALSO, 



Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. 



LAWRENCE WOLEF, M.D., 

Demonstrator of Chemistry, Jefferson Medical College ; Visiting Physician 

to German Hospital of Philadelphia ; Member of Philadelphia 

College of Pharmacy, etc. etc. 

THIRD AND REVISED EDITION, WITH AN APPENDIX. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 



Cincinnati Medical News, January, 1889. — " Wolff's Chemistry. — A little 
work that can be carried in the pocket, for ready reference in solving difficult 
problems/' 

St. Joseph's Medical Herald, March, 1889. — "Dr. Wolff explains most 
simply the knotty and difficult points in chemistry, and the book is therefore 
well suited for use in medical schools." 

Medical and Surgical Reporter, November, 1889. — " We could wish that 
more books like this would be written, in order that medical students might 
thus early become more interested in what is often a difficult and uninterest- 
ing branch of medical study." 

Registered Pharmacist, Chicago, December, 1890.— V Wolff 's Chemistry. " 
— " The author is thoroughly familiar with his subjects. A useful addition to 
the medical and pharmaceutical library." 

17 



No. 5. 



ESSENTIALS OE OBSTETRICS. 

By W. EASTERLY ASHTOK, M.D., 

Obstetrician to the Philadelphia Hospital. 



lb ILLUSTRATIONS. 
Third Edition, thoroughly revised and Enlarged, 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

c ; a 




Specimen of Illustrations. 

Southern Practitioner, January, 1890. — Ashton's Obstetrics. — An excellent 
little volume containing correct and practical knowledge. An admirable com- 
pend, and the best condensation we have seen." 

Chicago Medical Times. — 4i Ashton's Obstetrics. — Of extreme value to stu- 
dents, and an excellent little book to freshen up the memory of the practi- 
tioner." 

Medical and Surgical Reporter, January 26, 1889. — "Ashton's Obstetrics. 
— A work thoroughly calculated to be of service to students in preparing for 
examination.'' 

New York Medical Abstract, April, 1890. — "Ashton's Obstetrics should be 
consulted by the medical student until he can answer every question at sight. 
The practitioner would also do well to glance at the book now and then, to 
prevent his knowledge from getting rustv." 

18* 



No. 6. 

ESSENTIALS 

OF 

Pathology and Morbid Anatomy. 



C E. ARMAND SEMPLB, B.A., M.B., Cantab., L.S.A., M.R.C.P., Land, 

Physician to the Northeastern Hospital for Children, Harkney ; Pro- 
fessor of Vocal and Aural Physiology and Examiner in Acous- 
tics at Trinity College, London, etc. etc. 



ILLUSTRATED. FOURTH THOUSAND. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

From the College and Clinical Record, 
September, 1889. — " A small work upon 
Pathology and Morbid Anatomy, that re- 
duces such complex subjects to the ready 
comprehension of the student and practi- 
tioner, is a very acceptable addition to 
medical literature. All the more modern 
topics, such as Bacteria and Bacilli, and 
the most recent views as to Urinary Path- 
ology, find a place here, and in the hands 
of a writer and teacher skilled in the art 
of simplifying abstruse and difficult sub- 
jects for easy comprehension are rendered 
thoroughly intelligible. Few physicians 
do more than refer to the more elaborate 
works for passing information at the time 
it is absolutely needed, but a book like this 

of Dr. Semple's can be taken up and perused continuously to the profit and 
instruction of the reader." 

Indiana Medical Journal, December. 1889. — "Semple's Pathology and 
Morbid Anatomy. — An excellent compend of the subject from the point- of 
view of Green and Payne." 

Cincinnati Medical Neios, November, 1 889. 1 — Semple's Pathology and Mor- 
bid Anatomy. — A valuable little volume — truly a mult/on in parvo." 

19 




Specimen of Illustrations. 



Nu. 7. 

ESSENTIALS 

OF 

Materia Medica, Therapeutics, 

AND 

PRESCRIPTION WRITING. 



HENRY MORRIS, M.D., 

Late Demonstrator, Jefferson Medical College ; Fellow College of Fhysicians, 

Philadelphia; Co-editor Biddle's Materia Medica: Visiting 

Physician to St. Joseph's Hospital, etc. etc. 



SECOND EDITION. FOURTH THOUSAND. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 



Medical and Surgical Reporter, October, 1889. 
"Morris* Materia Medica and Therapeutics.— One of the best compends in 
this series. Concise, pithy, and clear, well-suited to the purpose for which it 
is prepared." 

Gaillard's Medical Journal, November, 1889. 
"Morris' Materia Medica.— The very essence of Materia Medica and Thera- 
peutics boiled down and presented in a clear and readable style." 

Sanitarium, New York, January, 1890. 
"Morris' Materia Medica.— A well-arranged quiz-book, comprising the 
most important recent remedies." 

Buffalo Medical and Surgical Journal. January, 1890. 
"Morris' Materia Medica.— The subjects are treated in such a unique and 
attractive manner that they cannot fail to impress the mind and instruct in 
a lasting manner." 

20 



Nos. 8 and 9. 

Essentials of Practice of Medicine, 

By HENRY MORRIS, M.D., 

Author of "Essentials of Materia Medica," etc. 

With an Appendix on the Clinical and Microscopical 
Examination of Urine. 

By LAWRENCE WOLFF, M.D., 

Author of " Essentials of Medical Chemistry," etc. 



COLORED (VOGEL) URINE SCALE AND NUMEROUS 
FINE ILLUSTRATIONS. 



SECOND EDITION, 

Enlarged by some THREE HUNDRED Essential 

Formulae, selected from the writings of the 

most eminent authorities of the 

Medical Profession. 

COLLECTED AND ARRANGED BY 

WILLIAM M. POWELL, M.D., 

Author of "Essentials of Diseases of Children." 



Price, Clotli, $2.00. Medical Sheep, $2.50. 

Southern Practitioner, Nashville, Tenn., January, 1891. 
"Morris' Practice of Medicine. — Of material aid to the advanced student 
in preparing for his degree, and to the young practitioner in diagnosing affec- 
tions or selecting the proper remedy." 

American Practitioner and News, Louisville, Ky., January, 1891. 
"Morris' Practice of Medicine. — The teaching is sound, the presentation 
graphic, matter as full as might be desired, and the style attractive. 7 ' 

Southern Medical Record, January, 1891. 
"Morris' Practice of Medicine is presented to the reader in the form of 
Questions and Answers, thereby calling attention to the most important lead- 
ing facts, which is not only desirable, but indispensable to an acquaintance 
with the essentials of medicine. The book is all it pretends to be, and we 
cheerfully recommend it to medical students." 

21 



No. 10. 

ESSENTIALS OF GYNECOLOGY. 



EDWIN B. CRAIGIN, M.D. ? 

Attending Gynaecologist, Roosevelt Hospital. Out-Patients' Department 
Assistant Surgeon, New York Cancer Hospital, etc. etc. 

58 FINE ILLUSTRATIONS. 

SECOND EDITION. 

Price, Cloth, $1.00. Interleaved for Notes, $1.25. 







Specimen of Illustrations. 



Medical and Surgical Re- 
porter, April, 1890. — "Craig- 
gin's Essentials of Gynaecol- 
ogy. — This is a most excel- 
lent addition to this series 
of question compends, and 
properly used will be of 
great assistance to the stu- 
dent in preparing for ex- 
amination. Dr. Craigin is 
to be congratulated upon 
having produced in com- 
pact form the Essentials of 
Gynaecology. The style is 
concise, and at the same 
time the sentences are well 
rounded. This renders the 
book far more easy to read 
than most compends, and 
adds distinctly to its value." 

College and Clinical Record, 
April, 1890. — " Craigin's 
Gynaecology.— Students and 
practitioners, general or spe- 
cial, even derive information 
and benefit from the perusal 
aud study of a carefully 
written work like this." 



22 



No. 11. 

Essentials of Diseases of the Skin. 

By HENRY W. STELWAGON, M.D., 

Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadel- 
phia ; Physician to the Skin Service of the Northern Dispensary ; Der- 
matologist to Philadelphia Hospital ; Physician to Skin Department 
of the Howard Hospital; Clinical Professor on Dematology in 
the Women's Medical College, Philadelphia, etc. etc. 

74 ILLUSTRATIONS, many of which are original. 



SECOND EDITION. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 




Specimen of Illustrations. 

New York Medical Journal, May, 1890.— " Stel wagon's Diseases of the 
Skin. — We are indebted to Philadelphia for another excellent book on Derma- 
tology. The little book now before us is well entitled " Essentials of Derma- 
tology. " and admirably answers the purpose for which it is written." The 
experience of the reviewer has taught him that just such a book is needed. 
We are pleased with the handsome appearance of the book, with its clear 
type, good paper, and fine wood-cuts." 



No. 12. 

ESSENTIALS 



Minor Surgery, Bandaging, and 
Venereal Diseases. 

By EDWARD MARTIN, A.M., M.D., 

Author of "Essentials of Surgery,'' etc. 

82 ILLUSTRATIONS, mostly specially prepared for this wcrk. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 



Medical News, Phila- 
delphia, January 10,1891. 
' 'Martin's Minor Surgery, 
Bandaging, and Venereal 
Diseases. — The best con- 
densation of the subjects 
of which it treatsyetplaced 
before the profession. The 
chapter on Genito-Urinary 
Diseases, though short, is 
sufficiently complete to 
make them thoroughly 
acquainted with the most 
advanced views on the 
subject." 

NasJiville Journal of 
Medicineand Surgery, ^io- 
vember,1890. — "Martin's 
Minor Surgery, etc., should 
be in the hands of every 
student, and we shall per- 
sonally recommend it toour 
students as the best text- 
book upon the subject." 
Pharmaceutical Era, Detroit, Michigan, December 1, 1890. — "Martin's 
Minor Surgery, etc. — Especially acceptable to the general practitioner, who 
is often at a loss in cases of emergency as to the proper method of applying a 
bandage to an injured member." 

24 




Specimen of Illustrations. 



No. 18. 

ESSENTIALS 



UF 

Legal Medicine, Toxicology, 



HYGIENE. 

BY 

C. E. ARMAOT3 SEMPLE, M.D., 

Author of " Essentials of Pathology and Morbid Anatomy. 



130 ILLUSTRATIONS. 



Price, Cloth . . $1.00. 

Interleaved for Notes .... 1.25, 



Southern Practitioner, Nashville, May, 1890. 

" Seraple's Legal Medicine, etc. — At the present time, when the 
field of medical science, hy reason of rapid progress, becomes so vast, 
a hook which contains the essentials of any branch or department of 
it, in concise, yet readable form, must of necessity be of value. This 
little brochure, as its title indicates, covers a portion of medical science 
that is to a great extent too much neglected by the student, by reason 
of the vastness of the entire field and the voluminous amount of matter 
pertaining to what he deems more important departments. The lead- 
ing points, the essentials, are here summed up systematically and 
clearly." 

Medical Brief, St. Louis, May, 1890. 
" Semple's Legal Medicine, Toxicology, and Hygiene. — A fair sample 
of Saunders' valuable compends for the student and practitioner. It 
is handsomely printed and illustrated, and concise and clear in its 
teachings." 

25 



No. 14. 

ESSENTIALS OF 

Refraction and Diseases of the Eye, 

By EDWARD JACKSON, A.M., M.D., 

Professor of Diseases of the Eye in the Philadelphia Polyclinic and College foi 
Graduates in Medicine; Member of the American Ophthalmological So- 
ciety; Fellow of the College of Physicians of Philadelphia; Fel- 
low of the American Academy of Medicine, etc. etc. 

AND 

Essentials of Diseases of the Nose and Throat, 

By E. BALDWIN GLEASON, M.D., 

Assistant in the Nose and Throat Dispensary of the Hospital of the University 

of Pennsylvania ; Assistant in the Nose and Throat Department of the 

Union Dispensary; Member of the German Medical Society, 

Philadelphia ; Polyclinic Medical Society, etc. etc. 

TWO VOLUMES IN ONE. PROFUSELY ILLUSTRATED. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 



University Medical Mag- 
azine, Philadelphia, Octo- 
ber, 1890. — " Jackson and 
Gleason's Essentials of Dis- 
eases of the Eye, Nose, and 
Throat. — The subjects 
have been handled with 
skill, and the student who 
acquires all that here lays 
before him will have much 
more than a foundation for 
future work." 

New York Medical Eec- 
ord, November 15, 1890. 
— "Jackson and Gleason 
on Diseases of the Eye, 
Nose, and Throat. — A 
valuable book to the be- 
ginner in these branches, 
to the student, to the busy practitioner, and as an adjunct to more thorough 
readino-. The authors are capable men, and as successful teachers know 

what a student most needs." 

26 




Specimen of Eye Illustrations. 



No. 15. 

ESSENTIALS 



DISEASES OF CHILDREN 



BY 

WILLIAM M. POWELL, M.D., 

Attending Physician to the Mercer House for Invalid Women, at Atlantic 
City, N. J. ; Late Physician to the Clinic for the Diseases of Chil- 
dren in the Hospital of the University of Pennsylvania and 
St. Clement's Hospital ; Instructor in Physical Diag- 
nosis in the Medical Department of the Uni- 
versity of Pennsylvania, and Chief of 
the Medioal Clinic of the Phil- 
adelphia Polyclinic. 



Price, Cloth $1.00. 

Interleaved for Notes .... 1.25. 



American Practitioner and News, Louisville, Ky., December 20, 1890. 
" Powell's Diseases of Children. — This work is gotten up in the 
clear and attractive style that characterizes the Saunders' Series. It 
contains in appropriate form the gist of all the best works in the de 
partment to which it relates." 

Southern Practitioner, Nashville, Tennessee, November, 1890. 
"Dr. Powell's little book is a marvel of condensation. Handsome 
binding, good paper, and clear type add to its attractiveness." 

Annals of Gynecology, Philadelphia, December, 1890. 
" Powell's Diseases of Children. — The book contains a series of im- 
portant questions and answers, which the student will find of great 
utility in the examination of children." 

27 



No. 16. 

ESSENTIALS 



EXAIIIATIOI OF URIIE. 



BY 



LAWRENCE WOLFF, M.D., 

Author of "Essentials of Medical Chemistry," etc. 



COLORED (VOGEL) URINE SCALE AND NUMEROUS 
ILLUSTRATIONS. 



Price, Cloth 



75 Cents. 



University Medical Magazine, 
June, 1890. 
" Wolff's Examination of the 
Urine. — A little work of decided 
value." 

Cv.?£%.$ 'k| Medical Record, New York. 
|H f^ffl^S^iL August 23, 1890. 

"Wolff's Examination of 
Urine. — A good manual for 
students, well written, and 
answers, categorically, many 
questions beginners are sure 
to ask." 




Specimen of Illustrations. 



Memphis Medical Monthly, Memphis, Tennessee, June, 1890. 
"Wolff's Examination of Urine. — The book is practical in char- 
acter, comprehensive as is desirable, and a useful aid to the student 

in his studies." 

28 



No. 18. 

ESSENTIALS 



PRACTICE OF PHARMACY. 



BY 



LUCIUS E. SAYRE, 

Professor of Pharmacy and Materia Medica in the University of Kansas. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 



Albany Medical Annals, Albany, N. Y., November, 1890. 
"Sayre's Essentials of Pharmacy covers a great deal of ground in 
small compass. The matter is well digested and arranged. The 
research questions are a valuable feature of the book." 

American Doctor, Richmond, Va., January, 1891. 
''Sayre's Essentials of Pharmacy. —This very valuable little manual 
covers the ground in a most admirable manner. It contains practical 
pbarmacy in a nutshell." 

National Drug Register, St. Louis, Mo., December 1, 1890. 
" Sayre's Essentials of Pharmacy.— The best quiz on pharmacy we 
have yet examined." 

Western Drug Record, November 10, 1890. 
"Sayre's Essentials of Pharmacy.— A book of only 180 pages, but 
pharmacy in a nut-shell. It is not a quiz-compend compiled to en- 
able a grocery clerk to ' down' a board of pharmacy ; it is a linker- 
post guiding a student to a completer knowledge." 

29 



No. 20. 

ESSENTIALS of BACTERIOLOGY. 



CONCISE AND SYSTEMATIC INTRODUCTION TO THE STUDY 
OF MICRO-ORGANISMS. 

BY 

M. Y. BALL, M.D., 

Assistant in Microscopy, Niagara University, Buffalo, N. Y. ; Late Resident 
Physician German Hospital, Philadelphia, etc. 



77 Illustrations, some in Colors. 



Price, Cloth, $1.00. Interleaved for Notes, $1.25. 




Specimen of Illustrations. 

Medical News, Philadelphia, Nov. 28, 1891. 
' ' The amount of material condensed in this little book is so great, and so 
accurate are the formula? and methods, that it will be found useful as a labor- 
atory hand-book." 

Pacific Record of Medicine and Surgery, San Francisco, Nov. 15, 1891 
" Bacteriology is the keynote of future medicine, and every pt^sician who 

expects success must familiarize himself with a knowledge of Germ-life — the 

agents of disease. 

" This little book with its beautiful illustrations will give the students, in 

brief, the results of years of study and research, unaided." 

30 



No. 21. 

ESSENTIALS OE 

Nervous Diseases and Insanity, 

THEIR 

SYMPTOMS AMD TREATMENT. 

By JOHN C. SHAW, M.D., 

Clinical Professor of Diseases of the Mind and Nervous System, Long Island 
College Hospital Medical School ; Consulting Neurologist to St. Cath- 
erine's Hospital, and Long Island College Hospital: Formerly 
Medical Superintendent King's County Insane Asylum. 



FORTY-EIGHT 
Original Illustrations. 



Mostly selected from the Author' 
private practice. 



Price, Cloth, $1,00. 

Interleaved for Notes, $1.25 



Boston Medical and Surgical 

Journal, Dec. 10, 1891. 
' ' Clearly and intelligently writ- 
ten." 

Medical Brief, Dec, 1891. 
"A valuable addition to this series 
of compends, and one that cannot fail 
to be appreciated by all physicians and 
students.'' 

Times and Register. 

New York and Philadelphia, Nov. 21, 

1891. 

" Dr. Shaw's Primer is excellent as 

far as it goes, the illustrations are well 

executed and very interesting." 




Specimen of Illustrations. 



31 



No. 22. 

ESSENTIALS OF PHYSICS. 



BY 



FEED. J. BROCKWAY, M.D., 

Assistant Demonstrator of Anatomy at the College of Physicians and Sur 
geons, New York. 



155 FINE ILLUSTRATIONS. 



Price, Cloth, $1.00 net. Interleaved for Notes, $1.25 net. 




Specimen of Illustrations. 



NOW READY. 



No. 17. 



ESSENTIALS OF DIAGNOSIS. 



BY 

S. SOLIS COHEX, M.D., 

Clinical Lecturer on Medicine, Jefferson Medical College, Philadelphia. 
ILLUSTRATED. 



Price, Cloth, $1.50 Net. 
32 






No. 23. 



Essentials of Medical Electricity. 



BY 



D. D. STEWART, M.D., 

Demonstrator of Diseases of the Nervous System and Chief of the Neurologi- 
cal Clinic in the Jefferson Medical College; Physician to St. Mary's 
Hospital, and to St. Christopher's Hospital for Children, etc. 



E. S. LAWRANCE, M.D., 

Chief of the Electrical Clinic and Assistant Demonstrator of Diseases of the 
Nervous System in the Jefferson Medical College, etc. 



SIXTY-FIVE ILLUSTRATIONS. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 




Specimen of Illustrations. 
33 



IN PREPARATION. 



For Sale by Subscription only. 



An American Text-Book 



MEDICAL AND SUEGIOAL 



DISEASES OF CHILDREN 



BY EMINENT SPECIALISTS. 



EDITED BY 
LOUIS STARR, M.D., 

Late Clinical Professor of Diseases of Children in the Hospital of the 
University of Pennsylvania. 



Uniform in size with the "American Text-Books of Surgery 
and Practice," it will be profusely illustrated with plain and 
colored plates, a large percentage of which will be original. 



SECOND EDITION . 

HOW TO EXAMINE FOR LIFE INSURANCE. 

By JOHN" M. KEATING, M.D., 

Medical Director Penn Mutual Life Insurance Co. ; Ex-President of the Association of Life 

Insurance Medical Directors; Consulting Physician for Diseases of Women at St 

Agnes' Hospital, Phila. ; Gynaecologist to St. Joseph's Hospital, etc. 

With two large Phototype Illustrations, and a Plate prepared hy Dr. McClellan 
from special Dissections; also, numerous cuts to elucidate the text. 

Price, in Olotli, 8$£5.00. 

PART I. has been carefully prepared from the best works on physical diagnosis, 
and is a short and succinct account of the methods used to make examina- 
tions ; a description of the normal condition, and of the earliest evidences of 
disease. 

PART II. contains the instructions of twenty-four Life Insurance Companies to 
their medical examiners. 



PRESS NOTICES. 

" This is the most practical manual on this subject that has yet been offered as 
a guide to the medical examiner for life insurance. The author has had a large 
experience as a medical director of one of the great life insurance companies, 
and it would, therefore, naturally be expected that he would deal with nothing 
but the useful and indispensable in a work of this kind. Every life insurance 
examiner should possess this book, even though he may be experienced in this 
work, for it contains much that is needful in the way of reference that cannot be 
found grouped elsewhere." — Buffalo Medical and Surgical Journal. 

" This unpretentious volume, from the pen of one of our most experienced and 
conservative life insurance medical directors, is just such a book as the young and 
inexperienced medical examiner needs. It is not a manual of Medical diagnosis, 
though founded upon the best works of that description. It contains those sug- 
gestive hints and recommendations that will be useiul to the medical beginner 
and that can only be furnished by the man of experience." — The American 
Journal of the Medical Sciences. 

" This is by far the most useful book which has yet appeared on insurance 
examination, a subject of growing interest and importance. Not the least valu- 
able portion of the volume is Part II., which consists of instructions issued to 
their examining physicians by twenty-four representative companies of this coun- 
try. As the proofs of these instructions were corrected by the directors of the 
companies, they form the latest instructions obtainable. If for these alone, the 
book should be at the right hand of every physician interested in this special 
branch of medical science." — The Medical News. 

"The volume is replete with information and suggestions, and is a valuable 
contribution to the literature of the medical department of life underwriters' work. 
— The United States Review (Insurance Journal). 

" Naturally, in the prevailing scheme of medical education, special instruction 
in the peculiar duties of the insurance examiner can have no place. The young 
physician may be never so good a diagnostician or pathologist, and yet fail to give 
satisfaction as a medical examiner. The book before us fills this want." — Tlu 
University Medical Magazine. 



Sent post-paid on receipt of price by the publisher, 

^ W. B. SAUNDERS, 

913 Walnut Street, Phila-, Pa. 

35 



In Press, Heady Shortly. 



A MANUAL OF 



Medical Jurisprudence and Toxicology, 



HENRY C. CHAPMAN, M.D., 

Professor of Institutes of Medicine and Medical Jurisprudence in the 
Jefferson Medical College of Philadelphia. 

Numerous Wood-Cuts and Colored Illustrations. 



A MANUAL OF 

PRACTICE OF MEDICINE. 



A. A. STEVENS, A.M., M.D., 

Instructor of Physical Diagnosis in the University of Pennsylvania. 

Specially intended for Students Preparing for Graduation and 
Hospital Examinations. 

Including the following Sections: General Diseases, Diseases of the 
Digestive Organs, Diseases of the Respiratory System, Diseases of tin; 
Circulatory Sj^stem, Diseases of the Nervous System, Diseases of the 
Blood, Diseases of the Kidneys, and Diseases of the Skin. Each Sec- 
tion will he prefaced hy a chapter on General Symptomatology. 

NUMEROUS ILLUSTRATIONS AND SELECTED FORMDLjE. 



A DOSE-BOOK 

AND 

Manual of Prescription-Writing. 



E. Q. THORNTON, M.D., 

Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 



The Fiske Fund Prize Essay for 1890. 

THE 

SURGICAL TREATMENT 

OF 

Wounds and Obstruction 

OF THE 

INTESTINES. 

BY 

EDWARD MARTIN, A.M., M.D., 

Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Sur- 
gery, and Lecturer on Minor Surgery, University of Pennsylvania; 
Surgeon to the Howard Hospital ; Assistant Surgeon to the 
University Hospital, etc. etc. 

AND 

HOBART A. HARE, M.D., 

Professor of Therapeutics, Jefferson Medical College ; Attending Physician 
to St. Agnes' Hospital. 



ILLUSTRATED. 



Price, Cloth $2.00, Net. 



" In presenting this Essay upon the Surgical Treatment of Wounds 
and Obstruction of the Intestines to the Trustees of the Fiske Fund, 
it is proper to outline the scope of our work, and to state briefly the 
facts and lines of original research upon which our conclusions are 
based. For over two years we have made experiments in the labo- 
ratory upon these subjects, and have carried out in every detail all 
the methods and modifications of operations that have been published 
or which have occurred to us in the course of our own studies. . . . 
In addition to the original work involved in studying so important 
a branch of surgery as the one before us (and which will be found 
represented, graphically, in part at least by a number of tracings), 
we have collected and placed before the reader what we believe to be 
the fullest statistics yet collected upon gunshot wounds of the abdo- 
men." — Extract from Preface. 

36 



INDEX 



PAGE 

Announcement 1 

American Text-Book of Surgery . . . . 2, 3 
American Text-Book of Practice . . . . 4, 5 
vlerordt and stuart's medical diagnosis . . 6 
Keating's New Unabridged Dictionary of Medicine 7 
Saunders' Pocket Medic ad Lexicon .... 8 
Nancrede's Anatomy and Manual of Dissection . 9 
DeSchweinitz's Diseases of the Eye . . . .10 

Garrigue's Diseases of Women 11 

Norris' Syllabus of Obstetrical Lectures . . 11 
Saunders' Pocket Medical Formulary . . .12 
Saunders" Series of Question Compends . . .13 

Hare's Physiology 14 

Martin's Surgery 15 

Nancrede's Anatomy 16 

Wolff's Chemistry ........ 17 

Ashton's Obstetrics 18 

Semple's Pathology, etc ..19 

Morris' Materia Medica . . . ' . . .20 

Morris' Practice of Medicine 21 

Cra gin's Gynecology 22 

Stel wagon's Diseases of the Skin . . . .23 

Martin's Minor Surgery, etc 24 

Semple's Legal Medicine, etc .25 

Jackson and Gleason's Diseases of Eye, Nose, and 

Throat 26 

Powell's Diseases of Children 27 

Wolff's Examination of Urine . . . . .28 

Sayre's Practice of Pharmacy 29 

Ball's Bacteriology . 30 

Shaw's Nervous Diseases and Insanity . . . 31 

Brockway's Physics 32 

Cohen's Diagnosis 32 

Stewart and Lawrance's Medtcal Electricity . 33 

Climatologist . . 34 

Keating's how to Examine for Life Insurance . 35 
Martin and Hare's Wounds and Obstructions of 

Intestines 36 

Index , 37 

37 



MEDICAL DIAGNOSIS 

BY 

DR. OSWALD VIERORDT. 



TRANSLATOR'S PREFACE. 

The work of which a translation is here offered is one of the 
best that has yet been written upon the subject. When it first 
came into the hands of the translator he had no thought of ever 
using it except as a work of reference. But as he read it he 
became convinced that it had such merit that it would certainly 
be welcomed by a large class of readers if it were rendered into 
English. Accordingly, after communicating with the author 
and his publisher, the work of translation was begun, and has 
been prosecuted at such intervals of time as could be secured 
from an active professional life. If the work shall commend 
itself to others as it has to him, the translator will feel amply 
rewarded for the effort he has made to put it into their hands. 

Here and there slight additions have been made, which the 
translator trusts will increase the value of the work. A very 
full index has been prepared, which, it is believed, comprises a 
reference to every material statement in the- book. 

The translation was almost completed when a copy of the 
second edition of the original was received from the publisher. 
The author has made numerous additions which have enhanced 
its value, and the translation has been made to correspond with 
this enlarged edition. It is gratifying to the translator to find 
that a second edition has so soon been called for, and that his 
own favorable opinion has been further confirmed by the fact 
that Italian and Russian translations of the. work have been 
made. 

FRANCIS II. STUART- 

123 joralemon street, brooklyn, n. y., 
March, 1891. 



[FACSIMILE.] 



c^^ ^ X^^^^^S4. , sit 

Jt4+<t£ ^**W Wz-^^L £4&2t&lc. <?7>£^&*4 c£r 






